| Patient: |
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| Age: |
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| Referring Doctor: |
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| Family Doctor: |
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| With what problems would you like the Doctor's help? |
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| What medical problems run in your family? |
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| Medications: |
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| Medical Problems: |
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| Previous Surgeries: |
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| Allergies to Medicines: |
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| How much do / did you smoke? |
packs / day. |
| How long have / did you smoke? |
years. |
| If you have quit, how long ago? |
years. |
| Do you drink alchohol? If so, frequency: |
# drinks / week. |
| Do you have any of the following symptoms? (Check any that apply) |
|
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mouth ulcers
unexplained weight change
double vision
chest pain
bloody sputum
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bloody urine
joint swelling
rash
depression
seizures
|
| For Pediatric Patients Only: |
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Was child full term?
If not, how many weeks?
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| Was the child breastfed? |
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Are immunizations current?
Does anyone at home smoke?
|
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| Is a wood-burning stove or fireplace used at home? |
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| Number of other children at home: |
. |
| Ages of other children: |
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| Is child in daycare or at home? |
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| |
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