How did you hear about us?

Name

First Last

Date of Birth

Martial Status

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home / Cell Phone

Personal Health History

Childhood Illness:

Details:

Immunizations and dates:

Details:

List any medical problems that other doctors have diagnosed

Surgeries:

Year

Reason

Hospital

Other Hospitalizations:

Have you ever had a blood transfusion?

Yes
No

Details (if Yes)

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers:

Name the drug

Strength

Frequency Taken

Allergies to medictaions:

Name the drug

Reaction you had

Health Habits and Personal Safety

All QUESTIONS CONTAINED IN THIS QUESTIONNARIE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL

Exercise:

Sedentary (No exercise)
Mild exercise (climbing stairs, walk 3 blocks, golf)
Occasional vigorous exercise (work or recreation, less than 4x/week for 30 mins)
Regular vigorous exercise (work or recreation 4x/week for 30 mins)

Details:

Diet

Are you dieting?

Yes
No

If yes, are you on a physician prescribed medical diet?

Yes
No

# of meals you eat in a average day?

Rank salt in take:

Hi
Med
Low

Rank fat intake:

Hi
Med
Low

Caffeine

Caffeine:

none coffee tea cola
# of cups/cans per day?

Alcohol

Do you drink alcohol?

Yes
No

If yes, how many drinks per week?

Are you concerned about the amount you drink?

Have you considered stopping?

Are you prone to "binge" drinking?

Do you drive after drinking?

Tobacco

Do you use tobacco?

Yes
No

Cigrettes-pks/day

Chew #/day

Pipe #/day

Cigar #/day

# of years

# of years quit

Do you currently use recreational or street drugs?

Yes
No

Sex:

Are you sexually active?

Yes
No

If yes are you trying for pregnancy?

Yes
No

If not trying for pregnancy, what contraceptives are you using?

Any discomfort with intercourse?

Yes
No

Illness related to the Human Immunodeficiancy Virus(HIV), such as AIDS, has become a major public health problem RISK

First Choice
Second Choice
Third Choice

Personal Safety

Do you live alone?

Yes
No

Do you have frequent falls?

Yes
No

Do you have vision or hearing loss?

Yes
No

Do you have an Advance Directive or Living Will?

Yes
No

Would you like information on the preparation of these?

Yes
No

Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?

Yes
No

Details (if yes)

Patient Form

Patient Form for Dr Danish

Personal Health History

OTHER PROBLEMS

Patient Form

Insurance