HISTORY FORM
DATE______/______/______ DOB_____/_____/______
( ) NEW TO DR. TAM ( ) ESTABLISHED PATIENT OF DR. TAM
( ) PREVIOUS PATIENT OF NALLE UNDER
DR. ________________________________
( ) OTHER PHYSICIANS AND ALTERNATIVE CARE
NAME________________________________________
ADDRESS_____________________________________
PROVIDERS__________________________________
PHONE (W) ______________ (H)________________
EMAIL (optional)_______________________________
LAST PAP_________ MAMMOGRAM_____________
LAST PHYSICAL EXAM_________________________
OCCUPATION_________________________________
MARITAL STATUS ( )SINGLE( )MARRIED( )OTHER
NUMBER OF CHILDREN_______________
| PAST MEDICAL HISTORY | SURGICAL HISTORY | LIFE STYLE HISTORY |
| ( )Heart Disease | ( )Heart Surgery | |
| ( )Rheumatic Fever | ( )Hernia Repair | ( )Smoke Tobacco |
| ( )High Blood Pressure | ( )Appendectomy | ( )Chew Tobacco |
| ( )Diabetes | ( )Hysterectomy | ( )Stressful Life Style |
| ( )Thyroid Disease | ( )Orthopedics | ( )Sleep Deprivation |
| ( )Stomach Ulcer | ( )Ulcer Surgery | ( )Sedentary Life Style |
| ( )Gallstone | ( )Gall Stone Surgery | ( )Eats Poorly |
| ( )Hepatitis | ( )Others | ( )Caffeine Use Amt. |
| ( )others | ( )Alcohol Use Amt. |
CURRENT MEDICATIONS:_________________________________________
NUTRITIONAL SUPPLEMENTS:_____________________________________
MEDICATION ALLERGY:___________________________________________
Father's Health History:
_______ Age if alive _______ Age when deceased
Mother's Health History:
_______ Age if alive _______ Age when deceased
Siblings' Health History: Any Family History of: (parents, siblings, and grandparents)
( )Heart Disease ( )Diabetes ( )Allergy
( )Cancer and Type:___________________
( )High Cholesterol ( )Thyroid Disease ( )Asthma
( )High Blood pressure ( )Prostate Problem
( )Others ____________________
WHAT IS THE MAIN REASON FOR YOUR VISIT TODAY?
____________________________________________________________