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Medical History
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Reason for today's visit:
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General State of Health:
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Occupation/Job:
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Marital Status:
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Sexual Hx
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Number of Children?
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Substances
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Nicotine Use?
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Smoking Years:
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Alcohol
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Comments
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Caffeine
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Comments
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Other substances
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Comments
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Weight and Exercise
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Happy with your weight?
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Patient's diet
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Exercise's regularly
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General Information:
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Primary Care Physician (PCP):
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Date of last PE
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Was last general blood work within normal limits:?
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If not please explain:
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Hormonal Issues?
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Do you have hormone issues?
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If Yes, please explain:
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Female History
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Age of onset of periods?
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Are your periods regular:
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# of pregnancies?
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# of miscarriages?
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Date of last menstrual period:
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Are you pregnant?
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Form of birth control:
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Age of "Change of Life":
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Do you do self breast exams?
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Past Medical History:
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Past Medical History
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Past Medical History Freewrite
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DISORDERS OF:
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Past Medical History Disorders - Freewrite
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Previous hospitalizations and/or surgery:
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Comments
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Hospitalizations and Surgeries
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Past Surgical History Multi Select
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Comments
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Cosmetic History
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Facial Surgery
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If yes, explain (include year):
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Have you ever had facial surgery?
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Do you have facial implants?
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If yes, explain (include year):
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List other cosmetic facial surgeries:
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Date of last dentist appointment
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Do you have an allergy to cows milk protein ?
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Do you have any immune system disorders ?
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If yes please list them.
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Do you have all of your adult teeth?
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If NO, explain:
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Botox
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If yes, locations:
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Dysport
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If yes, locations:
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Dermal Fillers
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If yes, locations:
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Reactions or issues:
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If yes, explain (where, when, how much):
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do not use
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Additional Information:
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