One Page Form DrPGx Medical History Form One Page First Name Last Name Home Address Home Address Home Address Home Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Is this also your mailing address? Yes No Mailing Address Mailing Address Mailing Address Mailing Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email * Please double check! Phone What is the best time to reach you? DOB Gender MaleFemale Race Marital Status Highest Level of Education Middle SchoolSome High SchoolGEDHigh School GraduateSome CollegeAABA/BSMastersDoctorate/PhD Your Goals What would you like to improve about your health? Add Remove Is there anything you are interested in knowing more about? Add Remove What do you hope to get out of your session? Is there anything else I can help you with? Healthcare Providers Primary Care Provider Group (If applicable) City Primary’s Phone Number Pharmacy Pharmacy City Phone Number Add Remove Have you seen any of the following healthcare professionals in the last year? None General Physician Physician Assistant / Nurse Practitioner Allergist Athletic Trainer Audiologist Cardiologist Chiropractor Dentist / Orthodontist Dermatologist Dietitian / Nutritionist Endocrinologist ENT Gastroenterologist Gynecologist Hematologist Infectious Disease Specialist Naturopathic Physician Nephrologist Neurologist Oncologist Ophthalmologist/OD Orthopedist Pain Management Specialist Podiatrist Plastic Surgeon Pulmonologist Physiatrist Psychologist Radiologist Rheumatologist Speech Pathologist Surgeon Urologist OBGYN OtherOther Have you been to the hospital in the past year? Yes No What was the reason for your hospital visit? Additional Comments Medical History Please list any medical illnesses or problems and provide details Medical Illness or Problem Such as Asthma or Acid Reflux Year Diagnosed If you have not been diagnosed, when did this issue begin Details Add Remove Have you ever had any medical issues or problems that are now resolved? Yes No Resolved Medical History Please list any resolved medical illnesses or problems and provide details Medical Illness or Problem Such as Asthma or Acid Reflux Year Diagnosed If you were not diagnosed, when did this issue begin Year Resolved Details Add Remove Family Medical History Please indicate any major conditions/illnesses that your immediate family members have had Family Member Such as Mother, Brother, Grandma or Daughter Condition and description Living? Yes No If deceased, at what age? Add Remove Additional Comments Main Residences This is to help understand environmental risks to your health that you may have been exposed to, such as living in Belle Glades with excessive farm burning occur and that could contribute to COPD risk due to the inhalation of smoke. Place of Residence ex: Orlando, Fl Start Year End Year Add Remove Occupational History This is to help understand occupational risks to your health that you may have been exposed to, such as an electrician being exposed to lead. Occupation ex: Painter Start Year End Year Add Remove Known Hazards or Risks You Have Been Exposed To + Year Ex. I was exposed to asbestos for 25 years and second hand smoking for 20 years Additional Comments Do you have any known medication allergies? Yes No Medication side effects can be described on the next page. Medication Allergies Medication ex: Penicillin Reaction Itchy Hives Welts Diarrhea Difficulty Breathing Anaphylaxis SJS TENs OtherOther Add Remove Do you have any known environmental allergies? Yes No Pets, Food, Plants, and Intolerances Environmental Allergies Allergen Reaction Itchy Hives Difficulty Breathing Anaphylaxis Congestion Watery Eyes Runny Nose Rash OtherOther Add Remove Additional Comments Medications Current Medications Prescriptions, Supplements, and Over The Counter Name / Dose / Strength / Route / Instructions Example-pril What do you take this for? High Blood Pressure Notes ex: 20mg Start/Stop Date Approximations are okay Add Remove Has a medication ever been discontinued in the past for any significant reason? Yes No This could be due to but not limited to price, no improvement of symptoms, or worsening of symptoms. Are you currently experiencing any side effects from your medication? Yes No Please describe your side effects: Additional Comments Surgical History Have you ever had any surgeries? Yes No Surgeries Description of Surgery Date Approximations okay Add Remove Do you plan to have any surgeries? Yes No Future Surgeries Description of Surgery Date Approximations okay Add Remove More about you Do you currently smoke? Yes No Years Smoked Packs a day Have you previosly smoked? Yes No Years Smoked Packs a day Do you consume alcohol? Yes No How many drinks per a week? Do you vape? Yes No How often and for how many years? Are you disabled? Yes No What is your disability? Do you use any of the following? Assistive Seating Blood Glucose Monitor Blood Pressure Machine Brace/Supportive Wear Colostomy Bag Crutches Deep Brain Stimulator Denture Electronic Pill Dispensing Device Hearing Aids Heart Monitor Insulin Pump Medical Alert Device Mobility Scooter Nebulizer Oxygen Vagus Nerve Stimulator Walking Cane Walker Wheel Chair OtherOther Height Weight (Lbs) Last Known Blood Pressure Last Known Blood Glucose Reading Additional Comments Appointment If you haven’t already booked your appointment please got to https://tinyurl.com/y2ue9dx5 to select a package, a date, and time. Have you ever had a genetic test before? Yes No Such as Ancestry, 23andMe, GeneSight etc. Which company and which test did you recieve? What year did you get this test? Would you like to know your genetic risk for developing Alzhiemer’s Disease? Yes No Additional Comments reCAPTCHA Submit Search for: Recent Posts A New Source – Deep Sea Mining Shopping Tools Zolgensma: A Cure For Spinal Muscular Atrophy CRISPR and Cas9 Gene-Editing Therapy Starting In The USA Recent CommentsArchives April 2023 May 2019 March 2019 Categories Articles Meta Log in Entries feed Comments feed WordPress.org
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