Douglas C - PatientPop



Dr. Douglas C. Shoenberger, PC

101 South Main Street, Suite 101

Coopersburg, PA 18036

610-282-1170 ph.

610-282-0256 fax

PAST MEDICAL HISTORY

PLEASE CIRCLE ANY OF THE FOLLOWING PAST MEDICAL PROBLEMS YOU MIGHT HAVE AND/OR ANY SYMPTOMS:

Heart, Lung, Liver, Gastrointestinal Diseases, Diabetes, Asthma, High Blood Pressure, Peripheral Vascular Disease, Breast Cancer, Gynecological Cancer, Prostatic Cancer, Colonic Cancer, Cancer (Unspecified),

Other___________________________________________________________________________________________________________________________________________

ALLERGIES:___________________________________________________________

MEDICATIONS:________________________________________________________________________________________________________________________________

PAST SURGICAL HISTORY:_____________________________________________

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Alcohol Use: NO YES __________________________Frequency

Tobacco Use: NO YES __________________________Packs per day

PLEASE CIRCLE ANY OF THE FOLLOWING PAST MEDICAL HISTORY IN YOUR FAMILY:

Heart, Lung, Liver, Gastrointestinal Diseases, Diabetes, Asthma, High Blood Pressure, Peripheral Vascular Disease, Breast Cancer, Gynecological Cancer, Prostatic Cancer, Colonic Cancer, Cancer (Unspecified),

Other___________________________________________________________________________________________________________________________________________

IS YOUR MOTHER STILL LIVING______, HOW OLD IS SHE______, AT WHAT AGE DID SHE DIE AND FROM WHAT_____________________________

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IS YOUR FATHER STILL LIVING_______, HOW OLD IS HE_______, AT WHAT AGE DID HE DIE AND FROM WHAT_____________________________

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PLEASE CIRCLE ANY OF THE SYMPTOMS YOU MAY BE EXPERIENCING:

Headaches, Blurry Vision, Double Vision, Difficulty Swallowing, Any Pain, Decreased Hearing, Fevers, Chills, Chronic Cough, Shortness of Breath, Sputum Production, Chest Pressure or Pain, Nausea, Vomiting, Diarrhea, Constipation, Black Tarry Stools, Bright Red Blood in Stools, Difficulty Urinating, Frequency, Urgency, Incontinence, Pain in Calves When Walking a Block or Less, Other___________________________________

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