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Patient Name:	*
Medications: Drugs and Doses
Medication Allergies:
Drug 1
Drug 2
Drug 3
Drug 4
Drug 5
Drug 6
Alcohol Use
Current Alcohol Use?:	No Yes
Drinks per week:
Tobacco Use
Current Tobacco Use?:	No Yes
Past Tobacco Use?:	No Yes
Date Quite:
Current Narcotic Abuse?:	No Yes
Type of Narcotic:
Past Narcotic Use?:	No Yes
Date Quite:
Family Information
Marital Status:	Single Married Divorced
Spouse's Name:
Exercise days per week:
Exercise Type:
Sexually Active?:	No Yes
Sexual Partners:	Male Female Both
Form of Protection:
Previous Doctor Name:
Previous Doctor Phone Number:
Do you see any specialists?:	No Yes
If so, what kind of specialist and who:

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