San Francisco Surgical Medical Group

San Francisco Surgical Medical Group
Name*

First NameLast Name
What name would you prefer to be called?
Date of Birth*
What is the reason for your visit today?*
Please detail any recent imaging you have had that is relevant to your medical condition. (Eg: CT Pelvis on 5/9/21 at Sutter Santa Rosa)
Who referred you to our practice?
Primary Care Physician (Enter full name, include address if not local)*
Other physicians you would like your reports to be sent to (full name + address if not local)*

Medications
Pharmacy information*
Please list the medications and supplements you take regularly, dosage amounts, and why? (If none, please write "None")*

Are you allergic to any of the following?*

Social History

	Single	Married	Widowed	Divorced	Domestic Partner	Decline
Marital Status

	Heterosexual	Homosexual	Bisexual	Decline
Sexual Orientation

	Never	Rarely	Moderate	Drinks/day
Use of Alcohol

	Never	Previously, but quit	Current packs/day	Comments
Use of Tobacco
Use of smokeless tobacco (snuff, chew, vaping)

	Never	Type/Frequency	Decline
Use of drugs

	Yes	No
Do you engage in anal-receptive intercourse?

Mark if your blood-related relatives have:

	Relative(s) - Include paternal/maternal info	Comments (Please specify)
Colon Polyps
Crohn's / Ulcerative Colitis
Thyroid / Endocrine Problems

	Height	Weight (lbs)
Amount