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HUDSON’S BAY MEDICAL GROUPINFORMATION FOR PHYSICIANS FORMPatient Name: _________________________ Date: ________________ Doctor: _________________Date of Birth: ________________ Place of Birth: ________________ Race/Nationality: _________________Religion: ____________________ Education: ___________________ Occupation: ______________________Married: ________ Single: ________ Divorced: ________ Widowed: ________ Domestic Partner: _________Live: Alone: ____________ Family: _____________ Assisted Living: _____________ Other: ______________Spouse/Partner’s Name: ______________________________ Occupation: ____________________________Children (List Sex/Birth Year): _________________________________________________________________Alcoholic Beverages: Now/ Past/ NeverTobacco Use: Now/ Past/ NeverRecreational Drugs: Now/ Past/ NeverSecondhand Smoke: Now/ Past/ NeverImmunization Dates:Tetanus (TD, DPT): ____________ Hepatitis A: ____________ Hepatitis B: ____________ MMR: ___________Pneumonia: ________________ Shingles: ________________ Tuberculosis Skin (TB): ____________________Procedure Dates:Colonoscopy: _____________________ Mammogram: _____________________ DRE: ____________________ (diabetic retinal exam)Surgeries: Have you had the following surgeries (R=Right, L=Left, B=Both)?Surgery: Date: Surgery:Date:Appendectomy ____________________ Hernia: Location ____________________Back Surgery:____________________ Hysterectomy ____________________Neck ____________________ Abdominal __________ Vaginal __________Low Back____________________ Ovaries left in _______ Ovaries out: R / L / BBreast Biopsy: R / L / B ____________________ Tubal Ligation ____________________Breast Implant: R / L / B____________________ Joint/Bone Surgery____________________Mastectomy: R / L / B ____________________Location ____________ Side: R / L / BCarotid Artery Surgery ____________________ Prostate Surgery ____________________Cataracts: R / L / B ____________________ Abdominal __________ Urethral _________LASIK Eye Surgery: R /L /B ____________________ Tonsillectomy ____________________Gallbladder-Type: Vasectomy ____________________Laparoscopic or open____________________Other Surgeries:____________________Family Medical History: **** Has anyone in your family had? For Aunts/Uncle/Grandparents, Pleaseindicate if they are Mother or Father’s side, and how old when they got the disease. ****Disease: Family Member:Disease: Family Member:Cancer: Coronary Artery Disease/Heart Disease:Breast _______________________ _____________________Colon _______________________ Kidney Disease_____________________Ovary _______________________ Depression _____________________Prostate _______________________ Anxiety _____________________Other _______________________ Alcoholism_____________________Colon Polyps _______________________ Thyroid Disease: _____________________Diabetes_______________________ Type: _____________________High Blood Pressure_______________________ Alzheimer’s Disease _____________________High Cholesterol _______________________ Migraines _____________________Stroke _______________________ Other: _______________ _____________________ 05/04/2020Name Continued: _________________________Past Medical History: Please circle if you Have Had or Have any of the following disorders/diagnoses (indicate on the line P=Past or C=Current)_____ ADD/ADHD_____ Headaches_____ Alcoholism_____ High Blood Pressure (Hypertension)_____ Allergies: Pollen/ Cats/ Dogs_____ High Cholesterol/Lipids (Hyperlipidemia)Dust Mites/ Others: _____________________ Transient Ischemic Attack_____ Allergic Rhinitis_____ Incontinence_____ Anemia_____ Irritable Bowel Syndrome:_____ AnxietySymptom: Diarrhea/Constipation/Pain_____ Arthritis: Degenerative/Osteoarthritis:_____ InsomniaWhat Joint: ____________________________ Kidney Stones_____ Asthma_____ Kidney Disease_____ Atrial Fibrillation_____ Liver Disease_____ Bee Sting Allergy_____ Low Back Pain_____ Bipolar Disorder_____ Migraine_____ Cancer:Type: _____________________ Neck_____ Colitis:Type: _____________________ Peripheral Artery Disease_____ Coronary Artery Disease_____ Prostate Enlargement_____ Congestive Heart Failure_____ Psoriasis_____ Colon Polyps_____ Pulmonary Embolism_____ Constipation_____ Restless Leg Syndrome_____ COPD/ Emphysema_____ Rosacea_____ Dementia_____ Seizure Disorder_____ Depression_____ Sleep Apnea_____ Diabetes:Type: _____________________ Stroke/TIA_____ Erectile Dysfunction_____ Thyroid Disorder_____ FibromyalgiaOveractive/Underactive_____ GERD/Heartburn_____ Tremors_____ Gout_____ Ulcer:Where: ___________________Other Diagnoses: _______________________________ Vein Clot__________________________________________________________________________________Medications: Please list all prescription and nonprescription medicationsMedications:Dosage/Instruction:__________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________ _____________________________________________________________________________________Medication Allergies: Reaction:_________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________Pharmacy Name: __________________________ Phone/Fax: ________________________________ 05/04/2020 ................
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