Chahfe Center - Publicforms

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PATIENT MEDICAL HISTORY FORM - Dr. Chahfe

PATIENT INFORMATION

Todays date *

Patient name *

Last Name, first name, Middle Inital

Gender *

Date of Birth *

Minor Patient

If patient is a minor, please tell us the name of the responsible party and the relationship

Patient Address *

Patient home phone number *

Please include area code

Patient cell phone number

Marital Status *

Single

Married

Divorced

Widowed

Occupation *

Please list your occupation

Occupation Status *

Full Time

Part Time

Retired

Student

PATIENT INSURANCE INFORMATION

Primary Insurance Carrier

Please list the name of your insurance and the address

Who is the subscriber?

Insurance ID number

Please bring your insurance cards with you to your appointment including any secondary or tertiary insurance you may have.

PATIENT ALLERGIES

Are you allergic to any medications? *

Yes

Allergies to medications *

Please list all medications you are allergic to and the reaction you had to the medication

PATIENT'S FAMILY MEDICAL HISTORY

Father *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Mother has or had.

What type of cancer

If you checked off cancer in the question above, please tell us what kind of cancer.

Mother *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Mother has or had.

What type of cancer?

If you checked off cancer in the question above, please tell us what kind of cancer.

Maternal Grandfather *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Grandfather has or had.

What type of cancer?

If you checked off cancer in the question above, please tell us what kind of cancer.

Maternal Grandfather *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Grandfather has or had.

What type of cancer?

If you checked off cancer in the question above, please tell us what kind of cancer.

Paternal Grandfather *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Grandfather has or had, or no known if none.

What type of cancer

If you checked off cancer in the question above, please tell us what kind of cancer.

Paternal Grandmother *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical Conditions

Living

Deceased

Please check any medical conditions your Grandmother has or had or no known if none.

What type of cancer

If you checked off cancer in the question above, please tell us what kind of cancer.

Brothers *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No Known Medical conditions

Living

Deceased

Please check any medical conditions your Brother has or had or check no known if none.

What type of cancer

If you checked off cancer in the question above, please tell us what kind of cancer.

Sister *

High Blood Pressure

Diabetes

Cancer

Heart Disease

Kidney Disease

No known Medical Conditions

Living

Deceased

Please check all medical conditions your sister has or had or check no known if none.

What type of cancer?

If you checked off cancer in the question above, please tell us what kind of cancer.

PATIENT SOCIAL HISTORY

Smoking Status *

Please use the drop down box to record your smoking status

Do you use illegal drugs? *

Yes

Illegal Drugs *

If you checked YES for illegal drugs please list the drugs you are taking

How much do you drink? *

Every Day

Occasionally

Never

PATIENT MEDICAL HISTORY

Do you have a history of the following *

Please check all medical conditions you have not or had in the past

Medical Conditions not listed above *

Please list any medical conditions you have had that are not listed above

PERINATAL HISTORY

Not Applicable

N/A

If you are a male, please check Not Applicable

Total pregnancy's *

How many Girls? *

How many boys? *

Did you have any complications during pregnancy *

N/A

Yes

Pregnancy Complications

If you checked yes in the previous question, please describe any complications you had with your pregnancy.

Is there a chance you are pregnant now? *

Yes

What is the reason you are seeing Dr. Chahfe? *

Please list the reason for the visit and if you are not sure, please list your symptoms

Please list all previous surgeries and the date of sugery *

If you have never had any previous surgery please type NONE in the box.

Please list all prescription medications you are taking, *

Please include dosage, how many times per day your are taking it and the reason you are taking each medication.

What type of cancer?

If you checked off cancer in the question above, please tell us what kind of cancer.

Please list all over the counter medications you are taking *

Please include dosage, how many times per day you are taking it and the reason you are taking each medication

PREVIOUS TESTS YOU MAY HAVE HAD

Please fill out the following information to the best of your ability. We use this information so Dr. Chahfe is able to review any previous tests you may have had ordered by other providers.

Have you had a CT scan of your Head, Neck or Chest in the last year? *

If yes, where and when?

Have you had a Chest X-ray in the last year? *

If yes, where and when?

Please tell us where you had your Chest X ray and

Have you had an MRI of your Head, Neck or Chest in the last year? *

If yes, where and when?

Please tell us if your MRI was of your Head, Neck or Chest and tell us where you had it and when

* Required field