Which racial category does the patient most closely identify with?
Ethnicity: What is the patient's ethnicity?
Complete - Only if Patient is a Minor
196 .Potient.information.Rev033017
PHARMACY (list pharmacy most frequently used for prescriptions)
Date (approximate) Hospital or city if known
Date (approximate) Hospital or city If known
OB/GYN HISTORY: No. of Pregnancies:
Are you an active cigarette smoker?
Is there a history in your family of:
Heart attack Diabetes Prostate cancer Kidney cancer Kidney stones Other significant disease
251.New.Palient.Medical.History.Adult.061316
Please check "X" the complaint(s) or ailment(s) that apply to you. If you are unsure, place a question mark (?)
Difficulty Achieving Erection Foul Odor in Urine
Weight Loss Weight Gain Other:
Dry Mouth Hearing Problems Hoarseness
Lumps/Swelling in Neck Sore Throat
Post Menopausal Bleeding Trouble Urinating Vaginal Discharge
Swelling in Feet/Ankles Other:
Anxiety Depression Difficully Sleeping/Concentrating History of Physical/Mental Abuse Mood Swings Stress
New.Patient.Medical.History.2021