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

H&P Med / Fam / Social History Medical Form

Family Practitioner

There are 2 copies in use.
Published: April 24, 2020, 6:48 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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Sunnyvale, CA 94089

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