Greensboro Medical Associates Health Information Form

Full Name

First NameLast Name

Age

Date of Birth

Date

Past Medical History

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)

List up to 15 current medications and dosages

Allergies to Medications

Hospitalizations/Surgeries

List up to 9 hospitalizations or surgeries (e.g., appendectomy, tonsillectomy)

Family History (check all that apply)

Family History Details

Tobacco: Packs Daily

Recreational Drug Use

Frequency per week of vigorous exercise

Alcohol Frequency

Alcohol Type

Alcohol Amount

Marital Status

Occupation

Children

If yes, age/name of children

Do you examine your skin daily?

Do you wear a seatbelt?

(Women) Do you perform monthly breast exams?

(Men) Do you perform monthly testicular exams?

Review of Symptoms

Please explain any "Yes" answer above

Greensboro Medical Associates Health Information Form - Endo