P H Y S I C I A N S T O

INC.

21 Highland Avenue SE, Suite 200 • Roanoke, VA 24013 Telephone (540) 982.8881 • Facsimile (540) 982.0612

To help us meet all your healthcare needs, please fill out this form completely. This is a confidential record of your medical history

and will be kept in this office.

Patient Name __________________________________________________ Birthdate ______/______/______ Age _______

Today’s date: ______/______/______ Date of last physical exam?______/______/______

1. PAST MEDICAL HISTORY — Have you ever had the following:

Patient denies any PMH2. PAST SURGICAL HISTORY — Have you ever had the following:

Denies any surgeries

Please list all serious illnesses and operations you have experienced and indicate year occurred

3. MEDICATIONS: Please list all medicines you are currently taking, including dosage and how often per day:

Denies any Medications 4. Please list all ALLERGIES (food, drugs, and environment)

Denies any Allergies_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Continued on next page

PATIENT MEDICAL HISTORY

— last Pap smear ____________ — last Colonoscopy ____________— last Mammogram ____________— last Bone Density ____________— Anemia ____________ — Endometriosis ____________ — Seizure ____________ — Cancers ____________— Heart Disease ____________— Uterine Fibroids ____________ — Thyroid Disease ____________— Diabetes ____________— Abnormal Pap ____________

— Irritable Bowel Disease ____________— Hepatitis ____________— PMS ____________— Stomach Ulcers ____________— Herpes ____________— Arthritis ____________— Hypertension ____________— Bone Fractures ____________— Headaches ____________— Sickle Cell Anemia ____________— Osteoporosis ____________— Pneumonia ____________ — Transfusions ____________

— Kidney Problems ____________— Stroke ____________— Bladder Infections ____________— Radiation Therapy ____________ — Skin Cancer ____________— Genital Warts ____________— Depression ____________— Leg/Lung blood clots ____________ — STD ____________— Asthma ____________— any other disease ____________

Hysterectomy ________________

Appendix ___________________

Tonsil ______________________

Cosmetic ____________________

C-Section ___________________

Gallbladder __________________

Knee Surgery _________________

Tubal Sterilization______________

D&C _______________________

Breast Biopsy _________________

Laparoscopy _________________

Other Surgeries _______________

Current Medications

______________________________

______________________________

______________________________

______________________________

Dosage (mg)

______________________________

______________________________

______________________________

______________________________

How often per day?

______________________________

______________________________

______________________________

______________________________

Upd

ated

8/2

9/11

Donna L. Musgrave, M.D.

Lynn M. Keene, M.D.

Dianna L. Curtis, M.D.

Eric D. Swisher, M.D.

Jill M. Arliss, M.D.

Jill A. Gaines, M.D.

Mark W Chewning, M.D.

Jamie J. Buck, M.D.

Margaret Grove, M.D.

Elizabeth Barwick D.O.

Brittany Kane D.O.

Stephanie Quinn-Philpot, RNC, WHNP

P H Y S I C I A N S T O

INC.

21 Highland Avenue SE, Suite 200 • Roanoke, VA 24013 Telephone (540) 982.8881 • Facsimile (540) 982.0612

5. FAMILY HISTORY: Has any blood relative had any of the following: (leave blank if uncertain)Denies family history of Breast Cancer Colon Cancer GYN Cancer

6. MENSTRUAL HISTORYAge of 1st period ________ Days between period ________ Flow: Light Medium Heavy ClotsTotal days on period ________ Last Period ________ Method of Birth Control ___________________________________Menopausal: Yes/No Age Menopause #________ Breakthrough bleeding: Yes/No Hormone Replacement Therapy: Yes/No

7. PREGNANCY:Total pregnancy # ________ Full Term # ________ Premature# ________ Ectopic # ________ Terminated # ________Miscarriages # ________ Multiple # ________ Living # ________

Pregnancy details:

8. SOCIAL HISTORY

Smoking (type & amount) ____________________________________________________________________________

If former smoker, date quit ___________________________________________________________________________

Alcohol (type & amount per week) _____________________________________________________________________

Street drugs (type & amount per day) ___________________________________________________________________

Occupation __________________________________________________________________________________________

Marital Status ________________________________________________________________________________________

PATIENT MEDICAL HISTORY (cont inued)

Relationship

Cancer _____________________

Type __________________________

Diabetes ____________________

Type __________________________

Heart Disease ________________

Osteoporosis _________________

Genetic Problem ______________

High Blood Pressure ___________

Seizure Disorder ______________

Stroke ______________________

Kidney Problems ______________

Leg/Lung Blood _______________

Birthdate Weight Gender Type of Delivery Complications Location

Upd

ated

8/2

9/11

Donna L. Musgrave, M.D.

Lynn M. Keene, M.D.

Dianna L. Curtis, M.D.

Eric D. Swisher, M.D.

Jill M. Arliss, M.D.

Jill A. Gaines, M.D.

Mark W Chewning, M.D.

Jamie J. Buck, M.D.

Margaret Grove, M.D.

Elizabeth Barwick D.O.

Brittany Kane D.O.

Stephanie Quinn-Philpot, RNC, WHNP