Microsoft word - patient questionnaire.doc

Name: ______________________________________________________ Age: ______________________
Chief Complaint: ___________________________________________________________________________________

Give age if living or age and cause of death.
Father _____________________________________ Mother _________________________________ Siblings ____________________________________ Children ________________________________ Is there an immediate family history (someone related by blood) of any of the fol owing: ALLERGIES AND SENSITIVITIES: Indicate which, if any are present:
MEDICATIONS: List al medications you currently take:
Sedatives, Sleeping Pil s, Tranquilizers Digitalis, Nitroglycerine, Cardiac Drugs Appetite Suppressants- including Phen-Fen SOCIAL HISTORY (circle one)

List al prior surgeries, as wel as cosmetic (including chemical peels).
Type: ________________________
Date: _________________________ Surgeon: ________________________ Date: _________________________ Surgeon: ________________________ Date: _________________________ Surgeon: ________________________ Did you experience any problems or complications during or fol owing above procedures? No________ Please explain_____________________________________________________ _________________________________________________________________________________________________
PAST MEDICAL HISTORY: List any prior hospitalizations below (e.g. accidents, surgeries, etc.).
Purpose: ______________________ Date: _________________________ Physician: _______________________
Purpose: ______________________ Date: _________________________ Physician: _______________________ Purpose: ______________________ Date: _________________________ Physician: _______________________ Have you recently been under the care of a physician for any reason?
If yes, please explain: ______________________________________________________________________________
Name, Address & Telephone Number of Physician: _______________________________________________________
REVIEW OF SYSTEMS: Check if any apply:

Is there any history not noted above of which the doctor should be aware? If yes, please explain: ______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This information is correct and true to the best of my knowledge. Patient Signature: ______________________________________________ Parent/Guardian Signature: _______________________________________


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