Medical Information Form

FIRST NAME:

Michael

LAST NAME:

Davis

MARITAL STATUS:

Single Married Divorced Separated Widowed

ADDRESS:

1568 Juniper Park

CITY:

Limestone

STATE:

PA

ZIP:

16234

PHONE:

(202) 659-4972

DOB:

08-20-1979

SPOUSE NAME:

SPOUSE PHONE:

Is the requested medication NEW or a CONTINUATION of THERAPY? If so, start date: __________

Have you been hospitalized in the past year? Yes No

Review of Symptoms

Allergies
Blurred Vision
Chest Pain
Coughing
Dental Problems
Double Vision
Excessive Bruising
Excessive Thirst
Fatigue
Headaches
Irregular Heart Rate
Muscle Pain
Shortness Of Breath
Tuberculosis Exposure

Black Outs
Calf Pain
Chills
Coughing Up Blood
Difficulty Emptying Bowel Or Bladder
Enlarged Glands
Excessive Stress
Eye Pain
Fever
Hearing Loss
Joint Swelling
Seizures
Stomach Trouble Or Ulcers
Weight Gain Or Loss Greater Than 10 Lbs

Social History

Do you smoke? Yes No

If yes, how many times per week: 1 2 3 4 5 6 7 8 9 10+

Do you drink? Yes No

If yes, how many times per week: 1 2 3 4 5 6 7 8 9 10+

Do you exercise? Yes No

If yes, how many times per week: 1 2 3 4 5 6 7 8 9 10+

Do you have a social support system? Yes No