Patient Information  

  Last Name:  
   
  First Name:  
   
  Date of Birth:  
   
  Age:  
   
  Date:  
   
  Pharmacy:  
   
  Pharmacy Phone Number:  
   
  Reason for visit:  
   
  Patient Weight (lbs):  
   
  Patient Height (ft'in''):  
   
  Contact Email:  
   

  Medications  

    Please list the medication and strength you are currently taking. (For example: Digoxin 0.125mg).

Name Medication Dosage/mg Quantity Brand


  Allergies  

    Please list all allergies and the reaction from any drugs

Name Allergies Reaction

  Past Illnesses  

    Please select Yes or No if you have had any of these illnesses in the past.

 
Anemia   Yes   No
  
Anxity   Yes   No
  
Arthritis   Yes   No
  
 
Asthma   Yes   No
  
Bone   Yes   No
  
Bronchitis   Yes   No
  
 
Cataract   Yes   No
  
Chronic fatigue   Yes   No
  
Heart disease   Yes   No
  
 
Depression   Yes   No
  
Diabetes I   Yes   No
  
Diabetes II   Yes   No
  
 
Eczema   Yes   No
  
Glaucoma   Yes   No
  
Hay fever/Allergies   Yes   No
  
 
Heart murmur   Yes   No
  
Hepatitis   Yes   No
  
Hypertension   Yes   No
  
 
Kidney stones   Yes   No
  
Memory loss   Yes   No
  
Osteoporosis   Yes   No
  
 
Pneumonia   Yes   No
  
Peptic ulcer   Yes   No
  
Psoriasis   Yes   No
  
 
Seizures   Yes   No
  
Stroke   Yes   No
  
TB   Yes   No
  
 
Thyroid   Yes   No
  
Cancer   Yes   No
  
Other   Yes   No
  

    If you selected yes to cancer or other illnesses. Please list the type of cancer or any other illness not list above!

Types of Cancer or Other Illnesses

  Previous Surgery  

    Please list any past surgery and date of surgery. If you have not had any surgery type none!

Previous Surgery Year

  Family History  

    Please select if any blood relative has suffered any of the following!
     
    Alcoholism Anemia Anesthesia complications Arthritis
    Asthma Bleeding Blindness Cancer
    Crib death Diabetes Hay fever Hearing loss
    Heart disease High cholesterol Hypertension Migraines
    Renal(kidney)disease Stroke Thyroid disease

  Social History  

    Please select the appropriate response!
       
  Use of alchohol:  
 
Never
 
Occasional
 
Moderate
Daily
  
       
  Use of tobacco:  
 
Never
 
Previous, but quit in
 
Daily  Packs/Day
  
   
 
Is there a history of exposure to second hand smoke?   Yes   No
       
  Use of recreactional drugs:  
 
Never
 
Previous, but quit in
 
Active use
 

  Review of Systems  

    Please select yes or no if you have had any of these symptoms!

Constitution
  
   
Appetite loss   Yes   No
  
Bad breath/taste   Yes   No
  
Chills   Yes   No
  
Fatigue   Yes   No
  
Fever   Yes   No
  
Difficulty sleeping   Yes   No
  
Daytime sleepiness   Yes   No
  
Weight loss-recent   Yes   No
  

Other
  
   
Night sweats   Yes   No
  
Travel out of U.S.   Yes   No
  
Head banging   Yes   No
  
Fussy/Irritable   Yes   No
  
Speech/Language difficulty   Yes   No
  

Eyes
  
   
Blurred vision   Yes   No
  
Double vision   Yes   No
  
Failing vision   Yes   No
  
Eye pain   Yes   No
  

Musculoskeletal
  
   
Muscle Weakness   Yes   No
  

Cardiovascular
  
   
Chest pain   Yes   No
  
Swelling of ankles   Yes   No
  
Heart palpitations   Yes   No
  

Psyciatric
  
   
Depression   Yes   No
  
Anxiety   Yes   No
  
Memory loss   Yes   No
  

Gastroenterology
  
   
Abdominal pain   Yes   No
  
Bloody stools   Yes   No
  
Constipation   Yes   No
  
Diarrhea   Yes   No
  
Heartburn   Yes   No
  
Persistent nausea   Yes   No
  
Persistent vomiting   Yes   No
  
ENT
  
   
Ear ache/pain   Yes   No
  
Ear drainage   Yes   No
  
Ear infection   Yes   No
  
Ringing in ears   Yes   No
  
Nose bleeds   Yes   No
  
Sinus problems   Yes   No
  
Sore throats   Yes   No
  
Snoring   Yes   No
  
Difficulty swallowing   Yes   No
  
Prolonged hoarseness   Yes   No
  
Decreased hearing   Yes   No
  
Decreased smell   Yes   No
  
Ear pulling   Yes   No
  

Respiratory
  
   
Chronic Cough   Yes   No
  
Shortness of breath   Yes   No
  
Shortness of breath On exertion   Yes   No
  
Shortness of breath Lying flat   Yes   No
  
Coughing blood   Yes   No
  

Neurology
  
   
Dizziness   Yes   No
  
Headaches   Yes   No
  
Numbness/tingling   Yes   No
  
Fainting spells   Yes   No
  

Skin
  
   
Rash   Yes   No
  

Hematology
  
   
Easy bruising   Yes   No
  
Transfusion history   Yes   No
  

Genitourinary
  
   
Blood in urine   Yes   No
  
Frequent urinary infections   Yes   No
  

     
   
     
     
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