Patient Information Form

Patient Information Form	Patient Name: Date: (mm/dd/yyyy)
	Birth Date: (mm/dd/yyyy) Sex: M F

Please list any allergies or intolerances to drugs or other substances:

Please list the names of your medicines, their dosages, strengths, and how many times per day you take them:

Family Medical History: Please list the ages of your family and any major illnesses they had.
AGES	Mother: Father: Sister(s): Brother(s): Children:
MAJOR ILNESSES	Mother: Father:
	Sister(s): Brother(s): Children:

Have any of the following medical conditioned occurred in your family? (check boxes)
tuberculosis	diabetes mellitus	high blood pressure	kidney disease
emphysema	li ver disease	epilepsy	neurological disorder
heart disease	anemia	hemophilia	thyroid disease
colon cancer	breast cancer	ovarian cancer	prostate cancer
osteoporosis

Doctor Notes:

Personal Information:
Occupation:	Highest Level of Schooling: High School College/Trade School Post-Graduate
Marital Status: Single Married Divorced Widowed Other
Do you smoke? Yes No	If yes, how much do you smoke?

If you are a former smoker, how long ago did you quit? mm/dd/yyyy)

Do you use smokeless tobacco? Yes No

How much caffiene do you have each day? 2 or less 3 to 5 6 or more
How often do you drink alcohol? Never or Rareley 0-3 times per week Nearly every day
How much do you usually drink when you have alcohol? 2 or less 3 to 5 6 or more
Do you have alcoholism or think you might? Yes No
Have you had a problem with substance abuse? Yes No
Sexual Orientation: Not Sexually Active Heterosexual Homosexual / Bisexual Other
Are you on a special diet?
How much do you exercise?
Do you have pets? Yes No

Doctor Notes: