PATIENT MEDICAL HISTORY FORM

How to use this Form:
u Use one Form per patient. DO NOT CLICK ON "BACK". If you do, all typed information will be erased.
u Type in the Form, on screen response, (fill out all applicable blanks).
u If you make a mistake, backspace and type again, or highlight the entire box and hit "Backspace".
u Provide applicable information in sections to be completed by patient.
u Press "TAB" to move between blank spaces. When finished, please click on "Send it in".

u PATIENT INFORMATION:
Date: Month Day Year
Medical Record #
.First Name M.I. Family Name
Sex: Male Female
Age: Years . Date Of Birth
Area Code Day Phone Number Night Phone Number
.E.Mail Address.......................
How Did You Hear About Us.
Referring Physician. .......
Primary Care Physician. .

u WOMEN Information:
.Pregnancies..Births Miscarriages.

u Medical Condition/Illness you seek treatment:
Diagnosis

Do You Smoke? Yes No

Are you taking medications for a chronic or a continuing medical problem?
The medications could be prescriptions drugs and or birth control medications, herbal supplements, vitamins... etc.
.Yes No
If yes, please type below the medical condition, names of medications and last date of use:

Race/Ethnicity (type X in applicable boxes):
.
.White/Caucasian
.Black/African American
.Asian/Asian American/Pacific Islander
.Hispanic/Latina
.Native American/Alaska Native
.Middle Eastern Descent
.Other: Please Type Here

Welcome to
Doctors Marketing Service
P.O. Box 748
Lake Forest, California 92609-0748

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