Medical History
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Reason For Visit:
Allergies:
Current Medications:
Past Medical History:
Past Surgical History:
Family Medical History:
Do you smoke cigarettes? If so, how many cigarettes per day?
Do you drink alcohol? If so, how many drinks per day?
Do you use illicit drugs? If so, how often?
Are you a vegan/vegetarian?
Yes
No
How many hours do you sleep per night?
< 6
6-8
> 8
How many days in a week do you exercise?
Do you feel stressed, anxious, or depressed most days?
Yes
No
Occupation
Females: When was your last pap smear? Mammogram? Colonoscopy?
Males: When was your last colonoscopy?
Advance Care Planning
In the case of an emergency, if my heart stops beating, I would like:
CPR, shocks, ACLS medications
To allow natural death
In the case of an emergency, if I cannot breathe in my own, I would like:
Intubation, respiratory support via a ventilator
To allow natural death
In the case of an emergency, if I am unable to eat, I would like:
Feeding Tube
To allow natural death
Signature
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