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

onpatient Additional Info Medical Form

Family Practitioner

Family Medicine New Onpatient Intake

There are 3 copies in use.
Published: Dec. 12, 2016, 9:57 p.m.
Doctor: Dr. History Physical
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328 Gibraltar Dr
Sunnyvale, CA 94089

Call us: (844) 569-8628

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