* = Required Information
S M W D


MEDICARE MEDICAID
BCBS POS
EPO HMO
OTHER

MEDICARE MEDICAID
BCBS PPO
POS EPO
HMO OTHER

MEDICATIONS: Prescription and vitamins, home remedies, birth control pills, herbs and other:

ALLERGIES or REACTIONS TO MEDICINES/FOOD/OTHER/OTHER AGENTS:

PERSONAL MEDICAL HISTORY: Please indicate whether you have had any of the following Medical conditions:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

SURGICAL HISTORY (Please list all prior operations and approximate date):

WOMEN'S GYNECOLOGIC HISTORY:

For Women:

Yes No NA

FAMILY HISTORY: Please check family member who have had any of the following medical conditions:

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

Mom
Dad
Brother
Sister
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Daughter
Son
Other

SOCIAL HISTORY:
Never Quit Current Smoker
Yes No
Yes No
Yes No
Yes No

SOCIOECONOMICS:
Grade school High school College Graduate
Single Separated
Divorced Widow
Other
Yes No Not Currently
Male Female NA
Yes No NA
Yes No NA
Yes No

IMMUNIZATION: Please list your most recent immunizations. Please include your best estimate of the month and year of each immunization:
Tetanus (Td)
Hepatitis A
Hepatitis B
Meningococcal
MMR
Pneumonia
Chicken Pox
Other

REVIEW OF SYSTEMS: Please check any current problems you have on the list below.

Fevers/chills/sweats
Unexplained weight loss/gain
Fatigue/weakness
Excessive thirst or urination

Change in vision
Double vision

Difficult hearing
Ringing I the ears
Problems with teeth/gums
Hay fever/allergies

Unexplained lumps
Easy bruising/bleeding

Chest pain/discomfort
Leg pain with exercise
Palpitations
Irregular heart beat

Chest pain/discomfort
Difficulty breathing

Abdominal pain
Blood in bowel movement
Nausea/vomiting/diarrhea
Heart Burns

Anxiety/stress
Problems wit sleep
Nausea/vomiting/diarrhea
Depression

Nighttime urination
Leaking urine
Unusual vaginal bleeding
Sexual function problems

Muscle/joint pain
Back pain

Rash or Mole change

Headaches
Dizziness/light-headedness

Memory loss

Above information is correct to the best of my knowledge and I release Sanjay Thakkar, MD of any liabilities as a result of false, incomplete or omitted information.

Security code