INTERNAL MEDICINE PATIENT INFORMATION FORMS
Your Name: ________________________________________
Age: _______ Birthday: ________________
Date: ______________________
Marital Status: _______________ # Children: __________
Do you have a LIVING WILL or ADVANCE DIRECTIVES? Yes/No
Allergies to medications: (please list medication and reaction)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List present medications:
Name:
Strength:
How often:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have or have ever had any of the following:
Breathing problems or asthma
Yes
No
Stroke
Yes
No
Diabetes
Yes
No
Tuberculosis
Yes
No
High Blood Pressure
Yes
No
Liver
Yes
No
Arthritis
Yes
No
Tumor or Cancer
Yes
No
Heart problems
Yes
No
Hormonal Problems
Yes
No
Ankle swelling
Yes
No
Steroids
Yes
No
Anticoagulants
Yes
No
Seizures
Yes
No
Digestive problems or ulcers
Yes
No
Smoker
Yes
No
Kidney problems
Yes
No
Use of alcohol
Yes
No
Genital or urinary problems
Yes
No
Anemia
Yes
No
Other: ____________________________________________________________________________________
Please turn over to complete Pg. 2
If Yes to any of the above, please detail: ________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What other physicians have you seen?___________________________________________________________
Have you ever been hospitalized? (Include date and purpose) ________________________________________
_________________________________________________________________________________________
Family History:
Father: Present age or age at Death ___________ If deceased cause of death __________________________
Circle One:
Heart Attack
Cholesterol problems
Stroke/TIA Cancer ________________________________
Hypertension
Diabetes
Alcoholism Other __________________________________________
Mother: Present age or age at Death ___________ If deceased cause of death __________________________
Circle One:
Heart Attack
Cholesterol problems
Stroke/TIA Cancer ________________________________
Hypertension
Diabetes
Alcoholism Other __________________________________________
Siblings: Present age or age at Death ___________ If deceased cause of death _________________________
Circle One:
Heart Attack
Cholesterol problems
Stroke/TIA Cancer ________________________________
Hypertension
Diabetes
Alcoholism Other __________________________________________
Grandparents: Present age or age at Death _______ If deceased cause of death ________________________
Circle One:
Heart Attack
Cholesterol problems
Stroke/TIA Cancer ________________________________
Hypertension
Diabetes
Alcoholism Other __________________________________________
Children: Present age or age at Death ________ If deceased cause of death ____________________________
Other __________________________________________
What is your occupation? _____________________________________________________________________
What type of hobbies do you enjoy? ____________________________________________________________
__________________________________________________________________________________________
How much exercise do you get a week and what type? _____________________________________________
_________________________________________________________________________________________
Signature: _____________________________________________ (Thank You for completing this form)