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Med-Cure Internal Medicine, PLC Date___________________ Name_____________________________ Age ____ Date of Birth _________________ Contact phone number ___________________________________________________ How did you find about us? _______________________________________________ Please list all other Physicians that are involved in your care (Pervious primary care physician, others) ADVANCED DIRECTIVES Do you have a living will? If no, would you like one? Yes______ Yes______ No_____ No_____ SOCIAL HISTORY Tobacco use Yes______ No_____ Alcohol use Yes______ No_____ Illicit drug use Yes______ No_____ If yes, how many a day_______ Duration__________________ Marital status and living arrangements_________________________________________ Occupation______________________________________________________________ ALLERGIES List all the medications and non-medications allergies. IMMUNIZATIONS Pneumovax___________________ Influenza_____________________ Tetanus_______________________ Other ________________________ Hepatitis_____________________ HPV________________________ Shingle________________________ FAMILY HISTORY Please circle the disease in your first degree or second degree relatives. Colon cancer Prostate cancer Breast cancer Ovarian cancer Diabetes mellitus Hypertension High cholesterol Stroke Heart disease (coronary artery disease) Other______________________________________________ PAST MEDICAL HISTORY Diabetes mellitus Hypertension Thyroid disease High cholesterol Stroke other hormone disease Carotid Artery Disease Congestive heart failure Cardiac arrhythmias Coronary artery disease Asthma COPD/emphysema/chronic bronchitis Osteoarthritis Osteoporosis/Osteopenia Pneumonia Fibromyalgia Rheumatoid arthritis Colon cancer Prostate cancer Melanoma Other cancer HIV infection Valley fever Herpes infection Other infections Depression/Anxiety Kidney stones Peptic ulcer Breast cancer Syphilis Dementia Rheumatic fever Seizure disorder Kidney disease Hiatal hernia Lung cancer Migraine Prostate problems Hepatitis Acid reflex disease G.I.bleed Other: ________________________________________________________________________ Health Screening Last colonoscopy________________ Last mammogram________________ Last pap smear__________________ Results: Normal/ Polyps/ Other Results: Normal/ Abnormal Results: Normal/ Abnormal PAST SURGICAL HISTORY Tonsillectomy Appendectomy Hysterectomy C. section Cholecystectomy Tubal ligation Hernia surgery Thyroid surgery Heart surgery (coronary artery bypass grafting/ valve surgery/Pacemaker-AICD) Orthopedic surgeries__________________________________________ Other______________________________________________________ MEDICATIONS Please list all prescribed and over-the-counter medications you are currently taking, including dose and frequency. NAME DOSE FREQUENCY
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