Who Is Your Primary Care Provider(Family Doctor)?______

Name: ______

Date of Birth: ______/______/______

Please note this form is not part of your permanent record. It is used to simplify data entry into the electronic medical record. It will be reviewed in depth by Drs. Wilk/Giacomi and discussed as necessary

If additional room is needed for any section, please use the reverse side

Who is your Primary Care Provider(Family Doctor)?______

Allergies & Reaction type (Medication, Food or Environmental)
Tobacco Use
Have you ever used Tobacco? YES NEVER
For Cigarettes:
How many years have you smoked?
How many packs per day (average)
Year Started:
Year Stopped
Cigars: Current Use? (Yes/No) Age Started: Age Stopped
Chewing Tobacco: Current Use? (Yes/No) Age Started: Age Stopped
Current Medications/Supplements/Birth Control
Name & Strength / How many times per day?
(i.e.: 1 pill daily, 1 pill 2x/day, etc…)
Medical Diagnoses (current or previous)
⏭Diabetes ⏭High Blood Pressure ⏭High Cholesterol ⏭Hypothyroidism
⏭Heartburn (GERD, reflux) ⏭Asthma ⏭Seasonal Allergies ⏭Headaches
⏭Depression ⏭Anxiety ⏭Fibromyalgia ⏭Gout
⏭Eczema ⏭Psoriasis ⏭Arthritis (location):
⏭Chronic Pain (where, onset): ⏭Stroke (year):
⏭Heart Attack (treatment, when)
⏭Cancer (type, onset)
OTHER(S):
Past Surgeries
Date (approximate) / Surgery/Reason (if not listed above)
Hospitalizations
Date (approximate) / Reason
Family History (please note maternal/paternal side if indicated)
Relative / Condition(s) / (Age at onset) / (Age at death)
Mother
Father
IF NOT LISTED ABOVE,
Has any family member had colon cancer?
Has any male family member had a heart attack prior to age 55?
Has any female family member suffered a heart attack prior to age 65?
Alcohol Use
Alcohol Use? Yes/No
Average number of beers/mixed drinks/glasses of wine per week:
Personal history of alcohol abuse at any time in your life? Yes/No
Have you felt a need to cut down on drinking? Yes/No
Have people annoyed you by criticizing your drinking? Yes/No
Have you ever felt guilty about your drinking? Yes/No
Have you ever needed a drink in the morning to steady nerves/ease a hangover? Yes/No
For All (Approximate dates OK)
Date of last annual physical:
Date of last Tetanus Vaccine:
Date of last Flu vaccine:
Date of last colonoscopy: Location/Doctor:
Date of last shingles vaccine:
For Women Only
Gynecologist name/location:
Last Pap Smear?
Any history of abnormal pap smear? When?
If abnormal, what was done?
Last Mammogram?
Any history of abnormal mammogram? When?
If abnormal what was done?
Other Medical Providers (list name, reason for visits or leave blank if none)
Cardiologist
Psychiatrist
Pulmonologist
Neurologist
Ear/Nose/Throat
Urologist
Allergist
Surgeon
Orthopedic Surgeon
Endocrinologist
Oncologist
(Other)