Greensboro Medical Associates Health Information Questionnaire - Internal Medicine, Dr. Pharr

Greensboro Medical Associates Health Information Questionnaire - Internal Medicine, Dr. Pharr

Please complete this form to provide your health and medical information. All information is confidential and used for your care.
NAME
AGE
D.O.B.

MonthDayYear
Date
PLACE OF BIRTH
PRIMARY CARE M.D.
OTHER DOCTORS YOU SEE
MARITAL STATUS
EMPLOYMENT STATUS
EMPLOYER
OCCUPATION
HOW WERE YOU REFERRED TO US
MAIN REASON FOR VISIT
EDUCATION (YEARS)
RELIGION
MILITARY SERVICE
REGULAR EXERCISE (TYPE)
REGULAR EXERCISE LEVEL
HOBBIES/SPORTS
SPECIAL DIET
SPECIAL DIET - IF YES, WHAT TYPE?
HABITS - HAVE YOU USED IV DRUGS?
HABITS - MARIJUANA?
HABITS - NARCOTICS?
HABITS - ETC.?
TOBACCO - TYPE?
TOBACCO - HOW MUCH?
TOBACCO - QUIT?
CAFFEINE - COFFEE (CUPS PER DAY)
CAFFEINE - TEA (CUPS PER DAY)
CAFFEINE - COLA (CUPS PER DAY)
ALCOHOL - TYPE?
ALCOHOL - HOW MUCH?
ALCOHOL - DAYS PER WEEK
ALCOHOL - QUIT
HISTORY OF BLOOD TRANSFUSION
AIDS BLOOD TEST
SEXUAL ORIENTATION
MEDICATIONS
DRUG OR FOOD ALLERGIES + REACTION
PREVIOUS SURGERIES
PREVIOUS INJURIES
PREVIOUS HOSPITAL STAYS
IN CASE OF EMERGENCY, CONTACT (Name)
EMERGENCY CONTACT ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
LIVING WILL
DNR ORDER
ADVANCE DIRECTIVES
FAMILY MEDICAL HISTORY - Mother: Age
FAMILY MEDICAL HISTORY - Mother: Medical Conditions
If Mother Deceased - Cause of Death
FAMILY MEDICAL HISTORY - Father: Age
FAMILY MEDICAL HISTORY - Father: Medical Conditions
If Father Deceased - Cause of Death
FAMILY MEDICAL HISTORY - Sisters: Age
FAMILY MEDICAL HISTORY - Sisters: Medical Conditions
If Sister Deceased - Cause of Death
FAMILY MEDICAL HISTORY - Brothers: Age
FAMILY MEDICAL HISTORY - Brothers: Medical Conditions
If Brother Deceased - Cause of Death
FAMILY MEDICAL HISTORY - Daughters: Age
FAMILY MEDICAL HISTORY - Daughters: Medical Conditions
If Daughter Deceased - Cause of Death
FAMILY MEDICAL HISTORY - Sons: Age
FAMILY MEDICAL HISTORY - Sons: Medical Conditions
If Son Deceased - Cause of Death
Any other medical conditions in relatives
Your general health
Your sleep quality
Your energy level
Have you had?
Females

Have You Had?
If You Have Never Had One Of The Below, Please Leave Blank
Last Colonoscopy

MonthDayYear
Date
Last Tetanus Vaccine

MonthDayYear
Date
Last Mammogram

MonthDayYear
Date
Last Pneumonia Vaccine

MonthDayYear
Date
Last Eye Exam

MonthDayYear
Date
Last Aortic Aneurysm Screen

MonthDayYear
Date
Last Pap Smear

MonthDayYear
Date
Last Hepatitis B Vaccine

MonthDayYear
Date
Last Bone Density

MonthDayYear
Date
I certify that the information I have given above is correct to the best of my knowledge.
If You Are The Patient And Filling This Out
Patient’s Signature
Date (patient signature)

MonthDayYear
Date
Patient mobile #
Please enter a valid phone number.Format: (000) 000-0000.
If You Are Not The Patient And Filling This Out
Signature of person filling out form
Relationship of person filling out form
Date (person filling out form)

MonthDayYear
Date
Should be Empty: