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Our Orchard Park Office is Moving to West Seneca - More Info

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PATIENT MEDICAL HISTORY

Patient First Name

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Patient Last Name

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DATE OF BIRTH

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RACE

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LANGUAGE

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Email

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ETHNICITY

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FAMILY PHYSICIAN & DATE OF LAST VISIT:

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ADDITIONAL PHYSICIANS THAT YOU WOULD LIKE TO RECEIVE A COPY OF YOUR VISIT SUMMARY:

1.

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3.

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2.

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4.

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PHARMACY NAME & PHONE

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REASON FOR TODAY'S APPOINTMENT:

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DRUG ALLERGIES

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MEDICATIONS WITH DOSAGE AND FREQUENCY (INCLUDING OVER THE COUNTER):

1.

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6.

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2.

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7.

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3.

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8.

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4.

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9.

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5.

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10.

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DO YOU SMOKE?

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PACKS PER DAY

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YEARS SMOKED

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IF NO, HAVE YOU EVER SMOKED?

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PACKS PER DAY

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YEARS SMOKED

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YEAR QUIT

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DO YOU DRINK ALCOHOL?

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IF SO, HOW OFTEN?

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ALL PREVIOUS SURGERY INCLUDING ANY BY OUR OWN PHYSICIANS: APPROXIMATE DATE

1.

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2.

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3.

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4.

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5.

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6.

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7.

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8.

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9.

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10.

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ANXIETY / DEPRESSION

FLU SHOT?

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DATE:

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PNEUMONIA SHOT?

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DATE:

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PERSONAL AND FAMILY HISTORY: (PLEASE INDICATE ALL THAT APPLY TO YOURSELF OR A FAMILY MEMBER)

ALZHEIMER'S DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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ANEMIA

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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ANEURYSM

LOCATION

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PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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ANXIETY / DEPRESSION

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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ASTHMA

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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ARTHRITIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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AUTOIMMUNE DISORDERS:

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PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CLOTTING DISORDER

TYPE

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PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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BRONCHITIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CANCER

TYPE

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PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CAROTID ARTERY DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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COPD/EMPHYSEMA

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CIRRHOSIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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COLITIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CONGESTIVE HEART FAILURE (CHF)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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CROHN'S DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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DEEP VEIN THROMBOSIS (DVT)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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DIABETES: ~ INSULIN-DEPENDENT

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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DIABETES: ~ NON INSULIN-DEPENDENT

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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FAINTING SPELLS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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FIBROMYALGIA

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART~ ATRIAL FIBRILLATION

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART~ MURMUR

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART~ PALPITATIONS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART ~ PACEMAKER / DEFIBRILLATOR

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART ~ VALVE DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEART ATTACK (MI)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HEPATITIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HIGH CHOLESTEROL

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HYPERGLYCEMIA / HYPOGLYCEMIA

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HIGH BLOOD PRESSURE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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HYPERTHYROIDISM / HYPOTHYROIDISM

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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KIDNEY

DISEASE

STONES

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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MULTIPLE SCLEROSIS (MS)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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PARKINSON'S DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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PERIPHERAL VASCULAR DISEASE (PVD)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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PHLEBITIS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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PROSTATE DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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PULMONARY EMBOLISM (PE)

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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RAYNAUD'S SYNDROME

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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SEIZURE DISORDER

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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THYROID DISEASE

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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VARICOSE VEINS

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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VERTIGO

PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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OTHER

please specify:

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PATIENT

FAMILY

RELATIONSHIP TO PATIENT

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