Health Number

Personal Details



SingleMarriedDivorcedWidowed


MaleFemaleOthers




YesNo


YesNo

Contact Details

Mailing Address

Emergency Contact

Medical Problems

NoneDiabetesHypertensionElevated CholesterolAsthmaHeart DiseaseStrokeCancerHIV/AIDSDepressionSeizuresStomach UlcersGlaucomaSTDPsychiatric Disorder

Medication List

Surgical History

NoneTonsillectomyAppendectomyGallbladder RemovalHysterectomyBowel SurgeryPlastic Surgery

Allergies List

NonePenicillinAmoxicillinTetracyclineAspirinIbuprofenNaproxenSulpha DrugsCarbamazepineLamotrigineErythromycinAzithromycinCodeinePseudoephedrine

Social History


No0-1 pack/day1-2 packs/day2+ packs/day


NoDailyWeeklyMonthlySocially


YesNo


YesNo

Travel History


YesNo

Reason for Today’s Visit

COVID 19 AdvicePrescription RefillGeneral Health QuestionCough/Cold/Flu/FeverSore ThroatEar/Eye/ThroatUrinary InfectionSkin Problem (Acne/Rash/Eczema/Moles/Warts)Erectile Dysfunction (Viagra, Cialis, Levitra etc)Birth Control or Plan BOther



Pharmacy Preference

Please arrange free medication deliverySend it to my own pharmacy

Current Physician(s) and Specialists