Medical History Questionnaire
Choose your Provider:
Please Select
Do Not Know
Michael Ayers, M.D.
Chad Cohen, D.O.
Michael DiBenedetto, M.D.
Francis Doyle, M.D.
Michael Geary, M.D.
John Haskoor, M.D.
Casey Kuripla, M.D.
Sandra Maguire, M.D.
Michael Marchetti, M.D.
Owen McConville, M.D.
Katherine Merra, M.D.
Jonathan Pribaz, M.D.
Michael Rowland, M.D.
Glen Seidman, M.D.
Andrew Thome, M.D.
Michaela Clark, PA-C
Molly Carleen, PA-C
Matthew Farraye, PA-C
Dana Fanning, PA-C
Caitlin Grahn, PA-C
Deanna Hathaway, PA-C
Bernie Hendriksen, PA-C
Elissa Peixoto, PA-C
Kerry Sepeck, N.P.
Stephanie Striglio, PA-C
Mikala Vertovec, PA-C
Emily Zaleski, PA-C
Dr. Christopher Rynne (Affiliated Doctor)
Full Name:
*
First Name
Last Name
Age:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Height:
Weight:
Occupation:
Please List your Pharmacy Name:
*
Pharmacy Phone Number:
Please enter a valid phone number.
Allergies
Do you have Any Known Allergies?
*
Please Select
Yes
No
Please list all allergies to medications, food or skin allergies (Tape, sutures, latex), their reactions, and level of reaction (mild, moderate, severe):
Current Medications
(Click Add Another to submit more than One Medication)
*
Medical History
Please check any conditions that pertain to YOU and clarify type if necessary:
Rows
Check Box if Condition Pertains to You
Type (if Required)
Anemia AND Anemia Type
Aneurysms
Angina
Artery Conditions
Asthma
Atrial Fibrillation (A-Fib)
Bladder Disease
Blood Disorder
Cardiac Stents
Liver Disease
Chronic Leg Ulcers
Color Blindness
Cancer AND Cancer Type
Diabetes - Type 1 (IDDM)
Diabetes - Type 2 (NIDDM)
Elevated Cholesterol
Emphysema
Gerd
Gout
Heart Attacks
Hepatitis AND Hepatitis Type
High Blood Pressure
Heart Failure
Hypothyroidism
Immune Deficiency
Kidney Disease
Lung Disease
Osteoarthritis
Osteoporosis
Peripheral Artery Disease (PAD)
Peripheral Vascular Disease (PVD)
Phlebitis
Deep Vein Thrombosis
Pulmonary Embolism
Rheumatoid Arthritis
Scoliosis
Pulmonary Embolism
Seizure Disorders
Sleep Apnea
GI Issues AND GI Type
Malignant Hypothermia
Stroke AND Stroke Type
TB AND TB Type
Other
Please check any of the following conditions if they pertain to a FAMILY MEMBER:
Rows
Check Box if Condition Pertains to You
Type (if Required)
Anemia AND Anemia Type
Aneurysms
Angina
Artery Conditions
Asthma
Atrial Fibrillation (A-Fib)
Bladder Disease
Blood Disorder
Cardiac Stents
Liver Disease
Chronic Leg Ulcers
Color Blindness
Cancer AND Cancer Type
Diabetes - Type 1 (IDDM)
Diabetes - Type 2 (NIDDM)
Elevated Cholesterol
Emphysema
Gerd
Gout
Heart Attacks
Hepatitis AND Hepatitis Type
High Blood Pressure
Heart Failure
Hypothyroidism
Immune Deficiency
Kidney Disease
Lung Disease
Osteoarthritis
Osteoporosis
Peripheral Artery Disease (PAD)
Peripheral Vascular Disease (PVD)
Phlebitis
Deep Vein Thrombosis
Pulmonary Embolism
Rheumatoid Arthritis
Scoliosis
Pulmonary Embolism
Seizure Disorders
Sleep Apnea
GI Issues AND GI Type
Malignant Hypothermia
Stroke AND Stroke Type
TB AND TB Type
Other
Surgical History
Have you ever had any surgical procedures?
*
Please Select
Yes
No
Procedure History
Social History
Do you smoke?
*
Please Select
Yes
No
Packs per Day:
Number of Years:
Are you a former smoker?
*
Please Select
Yes
No
Date when you stopped smoking (if necessary):
-
Month
-
Day
Year
Date
Do you use smokeless tobacco?
Please Select
Yes
No
Do you use alcohol?
*
Please Select
Yes
No
Number of Drinks per week?
What type of drink do you typically consume?
Beer
Malt Liquor
Wine
Mixed Drinks
Hard Liquor
Other
Do you have a history of OR use recreational drugs?
*
Please Select
Yes
No
If yes, please explain:
Do you have a history of substance abuse?
*
Please Select
Yes
No
If yes, please explain:
Do you have a history of mental condition (i.e. anxiety, depression, bipolar)?
*
Please Select
Yes
No
If yes, please explain:
Do you have or ever had a communicable disease (i.e. STD, Hepatitis, Chicken Pox, etc.)?
*
Please Select
Yes
No
If yes, please explain:
Submit
Should be Empty: