Microsoft word - adult physical form.doc

5 6 5 6 B E E C A V E S R D . , S T E E 2 0 0 ♦ A U S T I N , T X 7 8 7 4 6 ♦ ( 5 1 2 ) 3 2 8 - 8 8 8 0 ADULT DATABASE
NAME: ______________________________________ DATE OF BIRTH: _________________ DATE: ________________ AGE:________ SEX: MALE FEMALE Why have you come to see the doctor today? _______________________________________________ _________________________________________________________________________ (check all that apply):
Other:______________________________________ Other:______________________________________ GYN (WOMEN ONLY)
Age Menses began: _____ Date of Last Menstrual Cycle:___________ Birth Control Method using now: ________ Total # Pregnancies: ____ Full term pregnancies: ____ Living children:_____ Miscarriages:_____ Abortions:_____ Date of last Pap smear? __________Ever abnormal Pap?__________ Date of last mammogram? _______________ Do you perform regular monthly self breast exams? _______ VACCINES & CHILDHOOD DISEASES: (Please check all that you have had): Childhood vaccines
Pneumococcal (pneumonia) vaccine Hepatitis B vaccine Tetanus (most recent year): ________ LIST ALL HOSPITALIZATIONS, SURGERIES OR SERIOUS ILLNESS AND GIVE DATES

TYPE
__________________________________ _____ __________________________________ _____ __________________________________ _____ __________________________________ _____ __________________________________ _____
REGULAR MEDICATIONS (include vitamins, over the counter, birth control, herbal meds,)
(Example: Tagamet, 400mg, one 2 times a day)
Allergies/reactions to medications, food, latex, etc.: NAME ___________________________________________
DATE __________________
Age Medical Problems (List) and Cause of Death if Deceased Deceased?
r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ r ____ __________________________________________________________________ @ age___ n ____ __________________________________________________________________ @ age___ ____ __________________________________________________________________ @ age___ Has any member of your family had (check all that apply): Please explain any checked above:____________________________________________________________________ What is your occupation? ______________________________________________________________________ Marital Status: HIV/ Hepatitis risk factors: (check below) ( or check here if you do not wish to comment) Tattoos Homosexual contact IV drug use Multiple sexual partners Blood Transfusion If Current use: (Packs/day: ______ How many years? ______) Movitated to quit? Y N
If Previous use: (Quit when? _____ Smoked/Dipped how many years? _________)
How many drinks/week?: _________________________________
Explain: _______________________________________________ Diet: Good (low cal, low fat, high fiber). Average They know me by name at McDonalds. How many caffeinated drinks/ day? ___________________________________________________________________ Exposure to toxic chemicals: __________________________________________________________________________
Foreign travel in the past 6 months (Where?):_____________________________________________________________
Exercise Routine (what, how much, & how often):_______________________________________________________
Major Changes, stresses: _____________________________________________________________________________

Have you signed for organ donation? ________
Do you have a living will?________ (If not, please ask if you would like us to provide you with one.)

The above is complete and true to the best of my knowledge.

X
Sixteen Americans die each and every day because there aren’t enough available organs to save their lives. Please donate.

Source: http://www.westlakedocs.com/AdultDatabase.pdf