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Current & past medical and behavioral conditions
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List surgeries and hospitalizations with dates
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List 1st degree family & medical conditions
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Grandparents, Extended and Cancer Family History
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If age 18 or less, Birth Weight and History
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List your specialists/ other providers:
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Please enter preferred pharmacy?
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Can we leave a detailed phone message?
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Tobacco user? If yes, describe in detail.
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How many and type of caffeine per day?
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How many alcohol drinks per day or per week?
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Follow a certain diet or have food restrictions?
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Current or past recreational drug use (describe)
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Describe your exercise routine
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What is your occupation and/or are you a student
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Any hazardous or environmental exposures?
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Are you married, single, divorced, widowed, etc?
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Do you have children? Names & birth year
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Who lives in your home? Relationship and names
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List type and number of pets:
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Did you get complete HPV (Gardasil) vaccines?
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Date of tetanus vaccines? (Tdap and Td)
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Date of Flu Vaccine?
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If age 60 or above, Shingles Vaccine? (Zostavax)
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Date of adult Pneumovax Pneumonia Vaccine?
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Date of Prevnar13 Pneumonia Vaccine?
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Up to date on pediatric & other vaccines?
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Date of Colonoscopy?
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Date of last Bone Density?
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Females, date of last pap? Normal or abnormal?
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Females: Please list all pregnancies
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Date of last Mammogram?
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Females: Age menses started?
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Females: How often do you get your period?
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How many days does your period last?
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Females: Date of last menstrual period
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