History and Physical

Kathryn A. Wagner MD. PA. History Form
What is your name?

First NameLast Name
Birth Date

MonthDayYear
age
height in ft/inches format
weight in pounds
Your address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
preferred contact number

Area CodePhone Number
Cell phone number if different

Area CodePhone Number
email address
Insurance Company; bring your card please
What is your occupation?
Who is your employer?
What is your marital status?
What do you consider your ethnicity?
What is your language preference?
Enter the Name, address and phone number for your primary care doctor
Do you or have you ever smoked? How many packs or cig per day and for how many years? If you used to smoke, when did you quit, how much and for how long did you smoke?
Do you or have you ever taken illicit drugs including marijuana? Please list: [this is very important for anesthesia for surgery]
Do you drink alcohol? How much per day or week or month?
Now tell us why you are seeing the doctor:
Who referred you to Dr. Wagner?
Why are you seeing Dr. Wagner?
Can you tell us more about it?
Tell us about your past medical history:
Have YOU ever been diagnosed with cancer or precancerous condition?
Any other relatives with cancer? who, their relation to you, what kind of cancer, age at diagnosis: [Ex:Maternal grandmother breast cancer in her 60's]
Have you EVER had surgery? List what kind of surgery and approximate year performed: [Ex: appendectomy 1969]
Are you allergic to any medicines, foods, or other items? List please and reaction ex: penicillin rash
Are you allergic to Latex?
Do you regularly/frequently take aspirin or similar products?
I need a list of your current medicines with dose and how often you take them. Please type exactly as on the bottle; and bring them to your first appointment.
What vitamins, supplements, herbals, or teas are you taking? Please list exactly as on the bottle/package.
Have you had or currently have?
Do you have any ongoing medical problems not listed above? Please list:
How old were you when your periods started?
How old were you when you had your first child?
How many times have you been pregnant?
Have you had any miscarriages? How many?
Any abortions? How many?
What are the ages and sex of your children?
Did you nurse/breast feed? For how many weeks/months?
If you have had a hysterectomy, how many ovaries do you still have?
Have you ever taken birth controL or menopausal hormones? Please list and give approximate duration of use: [ex: oral contraceptives for 2 years]
Please list your other medical specialists [ex: Dr. John Smith cardiologist
Now tell us more about your family medical history
Has your mother, father, sister, brother or child been diagnosed with cancer? If yes, list their type of cancer and their age at the time of diagnosis:
specifically: has anyone in the family been diagnosed with breast, ovary, uterine, pancreatic, or colon cancer? Think about cousins also please.
Should be Empty:

Kathryn A. Wagner MD. PA. History Form

Now tell us why you are seeing the doctor:

Tell us about your past medical history:

Now tell us more about your family medical history