General Patient Information
Patient Name
*
First Name
Last Name
Patient Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
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Day
2021
2020
2019
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2012
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2009
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Patient Gender
*
Male
Female
Nonbinary
Transgender
Marital Status
*
Married
Single
Domestic Partner
Divorced
Widow (er)
Race
*
White
African American/Black
Native Hawaiian/Other Pacific Island
Asian
American Indian/Alaska Native
Other
Occupation:
*
The state of Texas maintains a free, confidential, secure, and voluntary vaccine registry called Immtrac. The registry is a very helpful resource to access your vaccination history. Do you consent to having SAMC report your vaccinations to Immtrac?
*
YES
NO
Personal Health History
*
No
Yes
Date of Diagnosis (or Approximate)
Heart attack/angina
Heart failure
Stroke
High Blood Pressure
High Cholesterol
Asthma
COPD or Emphysema
Colitis or Bowel Disease
Liver Disease
Kidney Disease
Bone or Joint Disease
Diabetes
Thyroid Disease
Migraines
Allergies
Skin Disease
Cancer
Depression
Anxiety
Sexually Transmitted Disease
Other illnesses:
*
Please list any drug allergies
*
Please list any Operations and Dates of Each
*
Please list your Current Medications
*
Alcohol Consumption? (If YES, how many drinks/week?)
*
Caffeine Consumption
*
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
*
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Have you ever smoked Tobacco? If so how long
*
Have you ever had blood or plasma transfusion? If yes when
*
Date of last diphtheria-tetanus booster
*
WOMEN Date of last menstrual period. Do you use birth control? If yes what kind? Date and results of last pap smear
*
Family Health History
*
No
Yes
Family members (specify if maternal or paternal)
Kind
Heart attack/angina
Heart failure
Stroke
High Blood Pressure
High Cholesterol
Asthma
COPD or Emphysema
Colitis or Bowel Disease
Liver Disease
Kidney Disease
Bone or Joint Disease
Diabetes
Thyroid Disease
Migraines
Allergies
Skin Disease
Cancer
Depression
Anxiety
Submit
Should be Empty: