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Patient Medical Information Sheet


Patient Information sheet to be filled out at initial Doctor's Office visit.




Medical Information Template



Patient Medical Information


Name:

________________________________

DOB: ____/____/______

Occupation:

________________________________

Education:

________________________________

Marital Status:

Single / Married / Divorced / Widowed

Tobacco Product Use:

None / Current Use / Past Use

Type of Product:

________________________________

How much per day?

________________________________

For how long?

________________________________

Daily caffeine consumption?

Yes / No

How much per day? ______

Alcohol Use?

Yes / No

How much per day?

________________________________

Do you currently exercise?

Yes / No

How often? ________

What type?

________________________________



________________________________



________________________________

Females:

Number of pregnancies _____

Number of Live Births _____

Type of delivery ________

Medication Allergies:

________________________________

Other Allergies:

________________________________

Medications:

________________________________

Current Medical Problems:

________________________________

Past Medical Problems:

________________________________

Family Medical History:

________________________________







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