Austin Regional Clinic: printable form

Name:______________________________ Date of Birth:_______________ Today’s Date:_______________

Personal/Social

Marital Status: Single Married Divorced Widowed Significant Other

Occupation _________________ Contraceptive method used__________________________

Use of alcohol:     Never      Socially        Drinks/Week__________
Use of street drugs:     Never       Type/Frequency____________________
Use of tobacco:     Never         Previously, but quit       packs/day_________
Do you use smokeless tobacco?_________

List any allergies and types of reaction :______________________________________________

Have you ever had surgery or been hospitalized?
No Yes If yes, please list the date(s) and reason(s)

Are you presently having problems with:
	Yes	No		Yes	No
Vision			Menstrual periods
Hearing			Thyroid disease
Heart disease			Bleeding from bowels
Breathing			Depression
Digestion			Dizziness, fainting
Urination			Sex Organs
Arthritis			Other
Rash or itching
Diabetes
Frequent headaches

Medical History

(Check all that apply)

Diagnosis	Self	Family Member	Diagnosis	Self	Family Member
Heart Disease			Arthritis
High Cholesterol			Osteoporosis
High Blood Pressure			Asthma or COPD
Stroke			Tuberculosis
Seizures			Alcoholism
Diabetes			Depression or Anxiety
Kidney Disease			Cancer, if so what type?
Glaucoma			Other

Medications: What prescribed and non-prescribed medicine(s) do you take?

1) ____________________________ 7) ____________________________

2) ____________________________ 8) ____________________________

3) ____________________________ 9) ____________________________

4) ____________________________ 10) ____________________________

5) ____________________________ 11) ____________________________

6) ____________________________ 12) ____________________________

Reviewed by: ______________________________ Date: _________________________

(Provider Signature)

_____________________________________ ____________________________