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Why are you here to see the doctor?
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Are you:
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Where did you find us?
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Do you have any Children? How Many?
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Which specialists do you see?
• • •
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Do you smoke, vape or use nicotine
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Who referred you?
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Do You drink Alchohol? If so, How May per day?
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Who is your Primary Care Physician?
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Do you use any recreational drugs? What kind and how much?
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Previous Surgeries and Dates
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What do you do for a living?
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Family History of Medical Problems
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What do you do for fun?
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Anything special we need to know
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