Carteret, NJ 07008 PATIENT INFORMATION PATIENT HISTORY · Current Primary Care Physician Date of...
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Transcript of Carteret, NJ 07008 PATIENT INFORMATION PATIENT HISTORY · Current Primary Care Physician Date of...
that regardless of my insurance company or the party requesting this exam, I am ultimately resposible for charges produced by DMCExamination. I also assign these physicians all payments for medical services rendered to my department or myself. I understandI hereby authorize Doctors Medi Center to release/furnish all information concerning my Diagnostic Test, History and Physical
DatePatient Witness
DEXA Scan Shingles Vaccine Tetanus Shot
Pap Smear MammogramMenstruation Breast Exam
Prostate Exam
Total Pregnancies Births Miscarriages
Pneumonio Vaccine ColonoscopyFlu Shot EKG
WHEN WAS YOUR LAST
WOMEN ONLY MEN ONLY
Diabetes Heart Disease Cancer Hepatitis Seizures TBFather’s Age: Mother’s Age: # of Siblings: Age(s):
FAMILYHISTORY
ALCOHOL CONSUMPTION
HeavyNone ModerateSocial
Frequency:# of Packs Per DayNoYes
If you quit, when?
Other Health Problems: Hospitalizations/Surgeries:
List All Current Medications
Allergies
HAVE YOU EVER SMOKED?
Please indicate whether or not you have had any of the following and whenPATIENT HISTORY
Heart disease, rheumatic feverHigh blood pressureChest pain, anginaAsthma, emphysemaShortness of breathChronic coughChronic bronchitisTuberculosisDiabetesAllergies, hayfeverSkin diseaseAnemia, blood diseaseCancer
Epilepsy, seizuresDizziness, fainting spellsFrequent or severe headachesUlcers, stomach troubleHepatitis, JaundiceKidney, bladder disorderArthritisBack injury or disorderKnee or joint problemsNervous or mental disorderBowel problems, colitisAlcohol or drug abuseHeart Attack
YesYesYesYesYesYesYesYesYesYesYesYes
YesYesYesYesYesYesYesYesYesYesYesYesYesYes
NoNoNoNoNoNoNoNoNoNoNoNoNo
NoNoNoNoNoNoNoNoNoNoNoNoNo
If Yes, When? If Yes, When? Circle OneCircle One
Social Security # - -
Current Primary Care Physician
/ / Date of Birth
Middle InitialFirst NameLast Name
Male Female
Occupation Company
Specialists
PATIENT INFORMATIONF: 732-969-2152T: 732-969-2240
Carteret, NJ 07008835 Roosevelt Ave
AND PHYSICAL FORMPATIENT HISTORYDOCTOR
MEDICENTERS
