Patient Information Sheet



| |Patient Information Sheet |

|Date: ________________ |(Male) |

| | |

| | |

| | | |

|Last Name |First Name |Middle Initial |

| |

|Home Phone |Work Phone |Cell Phone |

| | | |

|E-mail Address |Date of Birth |Marital Status |

ADVANCED DIRECTIVES

|Do you have: Durable Power of Attorney Living Will DNR(Do not Resuscitate) None of these |

| |

|Please let us know if you would like more information on any of the above items. |

MEDICATIONS & VITAMINS

Please list all of your medications, prescription and nonprescription, and the dosage amount:

|Medications |Dosage, how taken |

|1. | |

|2. | |

|3. | |

|4. | |

|5. | |

|6. | |

|7. | |

|8. | |

|9. | |

|10. | |

Please list all vitamins, supplements and other over the counter products.

|Vitamins/OTC |Dosage, how taken |

|1. | |

|2. | |

|3. | |

|4. | |

Please list medication ALLERGIES or medications you cannot take. Check here if NO allergies.

|1. |3. |

|2. |4. |

PHARMACY INFORMATION

| | | |

|Preferred Pharmacy Name |Pharmacy Phone Number |Pharmacy Address |

| |

|Alternative Pharmacy Name |Pharmacy Phone Number |Pharmacy Address |

Name: _________________________________

PAST MEDICAL HISTORY

Please place a check mark in the box if you have ever experienced any of the following conditions Also, if you know the year, please include it.

| |Year | |Year | |Year |

|Angioplasty | |Gastric Bypass | |Prostate Biopsy | |

|Angioplasty with Stent | |Hernia Repair | |TURP /Prostate Removal | |

|Appendectomy | |Hip Replacement | |Vasectomy | |

|Arthroscopic Knee Surgery | |Knee Replacement | |Other | |

|Back Surgery | |Lasik | | | |

|CABG/Bypass Surgery | |Liver Biopsy | | | |

|Carpal Tunnel | |ORIF/ Hip Fracture | | | |

|Cataract | |Pacemaker | | | |

|Cholecystectomy (Gallbladder) | |Small Bowel resection | | | |

|Colectomy (Colon Removed) | |Thyroidectomy | | | |

|Colostomy (Wear a Bag) | |Tonsillectomy | | | |

PAST DIAGNOSTICS

Please place a check mark in the box if you have ever had any of the following tests or procedures. Please include the last year this procedure was completed and the results, if known.

| |Approximate |Results (if | |Approximate Date |

| |Date |known) | | |

|If cigarettes, # of packs per day? ______________________ |Years smoked? __________________ |Date Quit? ______________ |

|Other tobacco (cans, cigars) per day? ______________ |Years smoked? __________________ |Date Quit? ______________ |

|Do you drink alcohol? | Currently | Never | Former | |Date Quit? ______________ |

|Type of alcohol? _______________________ | Daily amount? ________________ How often? ___________________________ |

| |

|Employer: ____________________________ Occupation: _______________________________ Year Retired _________________ |

| | | | | | | |

|Vaccine: |Date of last: |Vaccine: |Date of last: |

|Hepatitis A |1st:_______ / 2nd: _______ |Meningococcal | |

|Hepatitis B (3 shot series) |1st:______ / 2nd: ______ / 3rd: _______ |Pneumococcal | |

|HPV/Gardasil |1st:______ / 2nd: ______ / 3rd: _______ |Tetanus | |

|Influenza | |Varicella/Chicken Pox | |

| | |(childhood) | |

|Measles/Mumps/Rubella | |Herpes Zoster (adult) | |

Name: _________________________________

Please check the box if you are currently experiencing any of the following:

|General |Urinary |Skin |

|Chills |Dribbling |Contact Allergy |

|Fatigue/Tiredness |Dysuria/Pain on Urination |Hives |

|Fever |Hematuria /Blood in Urine |Itching |

|Feel Lousy/Malaise |Polyuria/Excessive Urination |Mole Changes |

|Night Sweats |Slow Stream |Rash |

|Weight Gain |Urinary Frequency |Skin Lesion |

|Weight Loss |Urinary Incontinence |Musculoskeletal |

|Eyes, Ears, Nose & Throat |Urinary Retention |Back Pain |

|Ear Drainage |Circulation |Joint Pain |

|Ear Pain |Blood Clots/Thrombophlebitis |Joint Swelling |

|Eye Discharge |Ulcer of the Feet or Legs |Muscle Weakness |

|Eye Pain |Metabolic/Endocrine |Neck Pain |

|Hearing Loss |Brittle Hair |Hematologic/Blood |

|Nasal Drainage |Brittle Nails |Easy Bleeding |

|Sinus Pressure |Cold Intolerance |Easy Bruising |

|Sore Throat |Hair Changes |Lymphadenopathy/Enlarged Lymph Nodes |

|Visual Changes |Heat Intolerance |Allergies |

|Respiratory/Lung |Hirsutism/Excessive Facial Hair |Environmental Allergies |

|Chronic Cough |Polydipsia/Excessive Thirst |Food Allergies |

|Cough |Polyphagia/ Excessive Eating |Seasonal Allergies |

|TB Exposure |Neurological |Male Reproductive |

|Shortness of Breath |Dizziness |Erectile Dysfunction/ED |

|Wheezing |Extremity Numbness |Penile Discharge |

|Cardiovascular/Heart |Extremity Weakness |Sexual Dysfunction |

|Chest Pain |Gait Disturbance/Difficulty Walking |Other |

|Calf Pain with Walking/Claudication |Headache |___________________ |

|Swelling, Fluid Retention/Edema |Memory Loss |___________________ |

|Heart Racing/Palpitations |Seizures |___________________ |

|Gastrointestinal/GI |Tremors |___________________ |

|Abdominal Pain |Mood |___________________ |

|Blood in Stools |Anxiety | |

|Change in Stools |Depression | |

|Constipation |Insomnia | |

|Diarrhea | | |

|Heartburn | | |

|Loss of Appetite | | |

|Nausea | | |

|Vomiting | | |

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Revised 12/11/12

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