Family Healthcare of Fairfax, PC
Please fill as completely as you can. If not sure, leave blank.
PAST MEDICAL HISTORY:
INCLUDE DATE AND NATURE OF PROBLEM
INCLUDE DATE, OPERATION/ HOSPITALIZATION, AND REASON
INCLUDE MEDICATION, DOSE, AND FREQUENCY OF USE
INCLUDE SUBSTANCE AND REACTION
Check those that apply, then in the space below indicate the Date you last received such medical care.
EDUCATION AND OCCUPATION:
For each family member, please indicate:
If they are living -- their age and health.
If deceased -- the cause and age at death
Below, please check any conditions had by a blood relative:
SEXUAL AND REPRODUCTIVE HEALTH
QUESTIONS FOR WOMEN ONLY:
QUESTIONS FOR BOTH MEN AND WOMEN:
QUESTIONS FOR MEN ONLY:
DIET & EXERCISE: