Greensboro Medical Associates Health Information Form - Endo
Please complete this form to provide your up-to-date health information for your endocrinology visit.
Full Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Past Medical History
None
List up to 15 past medical conditions (examples: diabetes, high blood pressure, hypercholesterolemia)
Current Medications and Dosages (If More Than 2, Please Bring Them With You)
None
List up to 15 current medications and dosages
Allergies to Medications
Hospitalizations/Surgeries
None
List up to 9 hospitalizations or surgeries (e.g., appendectomy, tonsillectomy)
Family History (check all that apply)
None
Family History Details
Rows
High Blood Pressure
Diabetes
Heart Attack (age)
Cholesterol
Stroke (age)
Cancer (type)
Deceased
Father
Mother
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Tobacco: Packs Daily
Please Select
0
½
1
1 ½
2
2 ½
3+
Recreational Drug Use
Yes
No
Frequency per week of vigorous exercise
Please Select
0
1
2
3
4
5+
Alcohol Frequency
None
Rare
Weekly
Daily
Alcohol Type
Beer
Wine
Liquor
Alcohol Amount
Please Select
0
1
2
3
4
5+
Marital Status
Single
Married
Separated
Divorced
Widowed
Occupation
Children
Yes
No
If yes, age/name of children
Do you examine your skin daily?
Yes
No
Do you wear a seatbelt?
Yes
No
(Women) Do you perform monthly breast exams?
Yes
No
(Men) Do you perform monthly testicular exams?
Yes
No
Review of Symptoms
Rows
Yes
No
Eyes/Vision
Ears/Hearing
Mouth/Nose/Throat
Heart/Chest
Nerves/Emotions
Skin/Rash
Stomach/Abdomen
Lungs/Breathing
Legs/Arms
Joints/Back
Groin/Genitals/Rectum
Last Menstrual Period
Please explain any "Yes" answer above
Submit
Should be Empty: