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NEW PATIENT MEDICAL HISTORY Nevada ph 515-382-5413 f 515-382-7108 Maxwell ph 515-387-8815 f 515-387-8817 Slater Name: ph 515-685-3960 f 515-685-3961 Zearing MR No: ph 641-487-7779 f 641-487-7749 DOB: PERSONAL HISTORY OF ILLNESS (Check any illness, past or present) Head injury Migraine headache Epilepsy (seizure) Mental illness Eye disease Other: Year 1. 2. 3. 4. Asthma Hay fever Thyroid disease Heart disease High blood pressure Lung disease Pneumonia Stomach ulcers Liver disease Kidney disease Anemia Diabetes Alcohol abuse Venereal disease Broken bones Skin trouble Gout/Arthritis High cholesterol Rheumatic fever Recurrent ear infection SURGERIES AND HOSPITALIZATIONS Surgery or reason for hospitalization Year Surgery or reason for hospitalization 5. 6. 7. 8. Are you allergic to any medications? Any other allergies (latex, rubber, etc.)? ALLERGIES Yes No If yes, what? FAMILY HISTORY Is there any history of the following diseases in your family? If yes, indicate which relative. DISEASE WHICH RELATIVE DISEASE Cancer Stroke Diabetes Asthma/Lung disease Depression WHICH RELATIVE Heart disease High blood pressure Tobacco/Alcohol abuse Reaction to anesthesia Other: SOCIAL HISTORY Married Widowed Single Divorced Occupation: Are you in a relationship where you feel unsafe: Yes No Caffeine use: No Children: No Yes-How many: (coffee, tea, cola) Exercise: No Yes-How often: Drug use: No Yes-How often: Alcohol use: No (Marijuana, LSD, Speed, Heroin, Methamphetamine, etc.) Tobacco use: No Yes If quit, how long did you smoke? How much: Do you have a living will/advanced directives? Clinic use only: Updated/Review Form 729G Rev 02/01/2011 (including beer and wine) Initial/Date: Yes Yes-How much: Yes-How much: N/A Year began: No Initial/Date: Do we have a copy? Yes Initial/Date: Nevada, Maxwell, Zearing, and Slater Medical Clinics are affiliates of Story County Medical Center No