Faith Family Medical Services
Faith Family Medical Services, LLC Medical History Briefly describe what problem brings you to the doctor: _______________________________________________________________________________________________________________________________________________________List all medications you are currently taking (Including the dosage, frequency, and any non-prescription medications):______________________________________________ _______________________________________________________________________________________________ _________________________________________________Medication Allergies: ______________________________________________ _______________________________________________________________________________________________ _________________________________________________Past Medical History: Please place a check mark if you or your family has ever had any of the following: Allergic Rhinitis ___ You ___FamilyAnemia ___ You ___FamilyAnxiety ___ You ___FamilyArthritis ___You ___FamilyAsthma ___You ___FamilyAtrial Fibrillation ___You ___FamilyAllergic Rhinitis ___ You ___FamilyCancer ___ You ___Family (type____________)Chest pain ___ You ___FamilyCongestive Heart Failure ___ You ___FamilyDepression ___ You ___FamilyDiabetes ___ You ___FamilyEmphysema ___ You ___FamilyGout ___ You ___FamilyHearing Loss ___ You ___FamilyHeart Attack ___ You ___FamilyHeartburn ___ You ___FamilyHerniated Disc ___ You ___FamilyHigh Blood Pressure ___ You ___FamilyHigh Cholesterol ___ You ___FamilyHypothyroid ___ You ___FamilyInsomnia ___ You ___FamilyIBS ___ You ___FamilyKidney Failure ___ You ___FamilyMigraine ___ You ___FamilyMitral Valve Disorder ___ You ___FamilyOsteoporosis ___ You ___FamilyStroke ___ You ___FamilyVisual Impairment ___ You ___FamilyAdditional Past Medical History:______________________________________________ _______________________________________________________________________________________________ _________________________________________________Past Gynecological History: Last Menstrual Period: _____________________ Number of Pregnancies: _____________ Live Births: ______________Past Surgical History: Surgery Date Surgery Date______________________________________________ _______________________________________________________________________________________________ _________________________________________________Family Medical History: Cause of Death Social History: Single Married Divorced WidowedFather Age_____ __ Living __ Deceased ________________ Do you or have you ever:Mother Age_____ __ Living __ Deceased ________________ Used Tobacco __Yes __No If, yes how much? ________________ Brother Age_____ __ Living __ Deceased ________________ If quit, when? ____________________Brother Age_____ __ Living __ Deceased ________________ Used Drugs __Yes __No If, yes how much? ________________ Sister Age_____ __ Living __ Deceased ________________ If quit, when? ___________________Sister Age_____ __ Living __ Deceased ________________ Drink Alcohol __Yes __No If, yes how much? ________________ If quit, when? ___________________Immunizations: Last Tetanus Shot? ____________Occupation: _____________________________________________ Pneumonia Vaccine? ____________Religion: ________________________________________________ Flu Shot? ________________If patient is a child, are immunizations up to date? Yes No Do you have a Living Will: Yes No (If yes, please provide our office with a copy) ................
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