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