* Patient's Name:

* Sex:	* Age:
M F

Marital Status:

Single

Married

Widowed

Divorced

* Patient's Social Security :

* Residence Address:

* City:		* State:		* Zip:

Office Phone:		* Cell Phone:

* Updated Home Phone:	* Emergency Contact Number :

Current Medications

Are you currently taking any prescription and/or non-prescription medications including vitamins,nutritional supplements, oral contraceptives, pain relievers, diuretics, laxatives, allergy medications and cold medications? If yes, list medications below.
	Yes		No

If Yes Name of Medication

Dosage (mgs)

How often taken

Update Past Medical History

Have there been any changes in your medical condition since your last visit here?
	Yes		No

If yes, describe

Have you seen a physician/healthcare provider since your last visit here?
	Yes		No

If yes, please complete the following:

Name

Date Seen

Specialty/Problems

Treatment

Update Family History

Have there been any births, deaths or major illnesses affecting your blood relatives since your last visit here?
	Yes		No

If yes, describe

Update Social History

Have there been any changes in your living arrangement, employment or education since your last visit here?
	Yes		No

If yes Describe

Substance

Currently use?

Type/Amount/Frequency

How long?

Caffeine

yes

Tobacco

yes

Alcohol

yes

Recreational/Street Drugs

yes

Review of Systems

Indicate whether you have experienced the following symptoms during recent weeks. Indicate the symptom(s) when multiple symptoms are listed.

Skin rash, sore excessive bruising
	Yes		No

Excessive thirst or urination
	Yes		No

Change of a mole
	Yes		No

Change in sexual drive or performance
	Yes		No

Significant headaches
	Yes		No

Diminished hearing, dizziness, hoarseness
	Yes		No

Sinus problem asthma
	Yes		No

Cough, shortness of breath, wheezing
	Yes		No

Coughing up sputum or blood
	Yes		No

Blackouts or loss of conciousness
	Yes		No

Chest pain, pressure
	Yes		No

Rapid or irregular heart beats
	Yes		No

Awakening at night short of breath
	Yes		No

Abnormal swelling in legs or feet
	Yes		No

Pain in calves when you walk
	Yes		No

Difficulty swallowing heartburn
	Yes		No

Nausea, vomiting, diarrhea
	Yes		No

Significant problems with constipation
	Yes		No

Blood in bowel movements
	Yes		No

Difficulty starting urinary stream
	Yes		No

Unable to completely empty bladder
	Yes		No

Leaking urine
	Yes		No

Burning or pain when urinating
	Yes		No

Pain, stiffness or swelling in back, muscles
	Yes		No

Fever, large lymph nodes
	Yes		No

At risk for HIV or AIDS
	Yes		No

Weight loss or gain of more than 100 lbs
	Yes		No

Experiencing an unusually stressful situation
	Yes		No

Problems falling asleep, staying asleep
	Yes		No

Sleep apnea, snoring
	Yes		No