Today's Visit

Name: Date: DOB:
Email:

Type of Insurance:

Do you smoke? Yes No How many cigarettes per day?

Please describe the main reason for today's visit:

Have you received any treatments, surgeries, or medications from any other doctors since your last visit? Yes No
If yes, please describe:

Have any of your first relatives (mother, father, sisters, brothers) developed any serious illnesses since your last visit? Yes No
If yes, please describe:

Have you experienced any allergies or adverse reactions to any medications since your last visit? Yes No
If yes, please describe:

Have you changed your lifestyle habits (diet, exercise, tobacco, or alcohol usage) since your last visit? Yes No
If yes, please describe:

List all medications (including over the counter & herbal) you are currently taking:

Medication	Dose	Frequency
1.
2.
3.
4.

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