Daoud Surgery and Family Medicine, PC

Today's Date * First Name * Last Name * Age * Date of Birth * Date of Last Physical What is the reason for visit? *

SYMPTOMS:

Check ( x ) symptoms you currently have had in the PAST WEEK which have changed:

General: * Do you feel safe at home * Muscle / Joint / Bone problems: * Eye problems: * Skin: * Ears, Nose, Throat: * Cardiovascular: * Pulmonary: * Gastrointestinal: * Genito-Urinary: * Explain any abnormalities you checked above:

CONDITIONS:

Check ( x ) conditions in which you have been diagnosed:

Diagnosed conditions you have: * Other or explanation to above diagnosis:

MEDICATIONS:

Please list all of your medications (including prescriptions, over-the-counter and herbals). Include also the name of the medication, dose of the medication and how you take the medication. If you don't take any medication write "none" on the line below:

Medications *

ALLERGIES:

Please list all of your allergies to medications or substances (i.e. Latex, Bees, foods, trees, etc.) and what reactions you have had. Write none if you don't have any:

Allergies: *

PAST SURGICAL HISTORY:

Please list all surgeries you have had. Write none if you haven't had any:

Surgery, Date, Where, Why: * Have you ever had a blood transfusion? *

FAMILY HISTORY:

Please list the names of family members, if they are alive or deceased (including age at death if deceased), any diseases your family members have had such as allergies, arthritis, asthma, Cancer, depression, diabetes, gout, heart disease, high blood pressure, etc.

Grandparents What are their names, age they were if deceased, other disease names and types of cancers Father * List father's name, age he was if deceased, other diseases and types of cancers if any Mother * List mother's name, age she was if deceased, other diseases or types of cancers if any: Brothers * List brothers names, age they were if deceased, other diseases or types of cancers if any: Sisters: * List sisters names, age they were if deceased, other diseases and types of cancers if any:

HEALTH HABITS:

What kinds of foods do you like to eat? * What kinds of exercise or sports do you like to do? *

Beside each substance tell if you have used in the past, when you started it, what type it was, how much you used and if you quit when:

Caffeine: * Alcohol * Tobacco: * Do you Vape or use Juuls? * Drugs: * Other

OCCUPATIONAL CONCERNS:

What grade are you in? * Are there any guns in the house? *

SEXUAL HEALTH HISTORY:

Please answer the following questions:

Are you sexually active? * If sexually active, what is the number of sexual partners in the past 5 years If sexually active, with whom do you like to have sex? Men, Women or both? Do you use any form of contraceptive (birth control) and what? *

I am either the guardian or am 16 and above and have permission from my parents to be seen. I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or members of his/her staff responsible for any errors or omission that I may have made in the completion of this form. Writing my name and date is the same as signing my signature.

Unless child is 16 and above Parent's First name: * Unless child is 16 and above Parent's Last name: * Relationship to child * Today's date *