Date

Full Name

Age

Phone Number

Best time / day to contact

Email

Religion

Gender

Marital Status

Weight

Height

Place of Birth

Do you smoke?

Do you use any drugs?

Have any allergies

Any special diet?

Do you drink?

Practice any sport?

Allergies to any medicine?

Current illness

Diagnostic

First Symptom Date

Diagnostic Date

Initial Symptoms

Available Lab Studies

Available X-Rays

Treatments received on the past

Current Symptoms

Other Illness present

Current Medication

Previous Surgeries (explain cause and date)

Special Requirements

Additional comments / questions

For Female Patients

Number of pregnancies

Vaginal births

C-sections

Abortions

Menopause

Using hormone therapy