Please  check  if  someone  in  your  family  has  had  any

Self   RelationMigrane Hearing  Problems Nausea/VomitingSeizures Hoarseness Abdominal  PainEye  Disease Vision  Problems DiarrheaHearing  Disorder Sinus  Trouble ConstipationAngina Hayfever/Sneezing Rectal  BleedingHeart  Attack Headaches Erection  ProblemsHigh  Blood  Pressure Post  Nasal  Drip Genital  LesionsDiabetes Fever Genital  DischargeStrokes Ear  pain Excessive  UrinationHigh  Cholesterol Nose  Bleeds Painfull  UrinationLung  Disease Lumps/Glands Back  PainPheumonia Shortness  of  Breath Skin  Rashes/MolesBronchitis Asthma/Wheezing Weight  Loss/GainStomach  Ulcer Irregular  Pulse Easy  BruisingLiver  Disease/Hepatitis Varicose  Veins Night  SweatsIrritable  Bowel Muscle  Cramps WeaknessCrohn's/Colitis Leg  Sweling NumbnessKidney/Bladder  Problems Leg  Pain TremorsNeurological  Problems Loss  of  Appetite FatigueArthritis Heartburn Dizzy  SpellsOsteoporosisCancerBleeding  DisorderAnemiaThyroid  ProblemsAlcohol  AbuseMental  IllnessDepression/AnxietyAsthmaAlzheimer'sSexually  Transmitted  Dx

ORLANDO  FAMILY  PRACTICE  CARE,  P.A10967  Lake  Underhill  Rd  suite  122Orlando,  Fl  32825P:  407-­‐282-­‐3131    F:  407-­‐282-­‐3139

PATIENT  QUESTIONNAIRE

PAST  MEDICAL  AND  FAMILY  HISTORY REVIEW  OF  SYMPTOMS

of  the  following  conditions:Please  check  if  you  currently  are  having  any  of

following  problems:

Date  of  Birth  _________/__________/_________

Name_______________________________________________________________ Date___________________________

MammogramPAP

MEDICATIONS IMMUNIZATIONSDate  of  last:List  all  medications  that  you  take:

Flu  Shot_______________Pneumonia  shot________Tetanus  shot___________

PAST  SURGICAL  HISTORYPlease  list  all    surgeries  and  dates:

SOCIAL  HISTORY

Please  list  all  drug  allergies:Do  you  have,  or  have  you  ever  consumed:

Cigarettes          ______yes    ______No    Packs  per  day_______  #  of  Years  _______Alcohol                    ______Yes    ______No      Drinks/Week______________________

ALLERGIES

Street  Drugs    ______Yes    ______No      Type:____________________________RESULTSITEM DATE  (approximate)

Caffeine                  ______Yes    ______No      Cups/Day_________________________

Are  you  PREGNANT  or  is  there  a  chance  you  could  be  PREGNANT?        YES____________  NO____________

Sigmoidoscopy  or  ColonoscopyPSA  (Prostate  Blood  Test)Cholesterol  Screening