For Office Use Only:
Patient’s MRN: __________________
Patient Name:
Date of Birth:
Please print all information in the sections below:
Current Medications (include over-the-counter medicines,
dosage and instructions)
Start
Date
Past Surgical History
Stop
Date
Date
Tobacco Use:
 Current
Packs per day:
Year Started:
Year Quit:
Alcohol:
 Former
 Never
Drinks per day:______
Drugs:
 Current
 Previous
 Never
 Current
Type:_________________
 Previous
 Never
Other: _______________

Current Allergies (list below)

Other:____________________

Advance Directives
Other: _______________
 Living Will
 Power of Attorney
 Do Not Resuscitate
 Other ___________
Gynecological History
Age first started period:
First day of last period:
Usual # of days of flow:
Last pelvic exam:
Date of last pap smear:
Date of last Mammogram:
Usual number of days from one period to the next:
Cramps with periods?
Are your periods:
Any excessive bleeding or spotting between cycles?
Comments:
 Yes  No
 Light  Moderate  Heavy
 Yes  No
Obstetric History (List all pregnancies, dates, and outcome)
Pregnancy(s) Outcome:  Delivered
Count:_______
 Miscarriage Count:_______
 Abortion
Count:_______
Date
Gestational
Sex
Weight
Delivery Mode
Duration
(C-section or Vaginal)
Complications
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Past Medical History (Select all that apply)
Past Family History (Select all that apply)
Other: _______________
Other: _______________


Adult Immunization History (Date of Immunization)
Hepatitis A & Hepatitis B
Hepatitis A (Hep A)
Hepatitis B (Hep B)
Flu (Influenza)
Pneumonia(Pneumococcal)
Tdap (Whooping Cough)
Typhoid
Current Pharmacy
Pharmacy Name:

Yellow Fever
Chickenpox (Varicella)
Shingles (Herpes Zoster)
MMR (Measles, Mumps, Rubella)
Meningitis (Meningococcal)
Rabies
Td (Tetanus, Diphtheria)
Pharmacy Phone #:
Other:____________________
HPV(Human Papillomavirus)
Polio
Japanese Encephalitis
Other:____________________
Other:____________________
Other:____________________
Other:____________________
Pharmacy Address
This section is to be completed by the Physician only
Please use the table below to list all of the patient’s current problems:
ICD-9
Current Problems
Onset Date
Code
ICD-9
Code
Current Problems
Please review all of the information that the patient has completed. If there are any changes, please update appropriately.
Physician Signature
Date
2
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Onset Date