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Rockville Internal Medicine Patient Intake Form Date: ____________________________________ “PLEASE PRINT” (mark preferred # with a *) PATIENT NAME: _____________________________________ Home Phone # :_________________ LAST FIRST MI Cell Phone#:____________________ Work Phone #:___________________ NICKNAME: ______________________________________ ADDRESS: _______________________________________ _______________________________________ _______________________________________ E-MAIL: _________________________________________ Date of Birth:__________________ Gender: Male Female Married: Yes No Children: Yes No Emergency Contact Name:____________________________________ Phone #:___________________ Relationship to Patient:_____________________________ Reason for Visit:_______________________________________________________________________ Referred By: _________________________________________ MEDICAL PROBLEMS (past or current) e.g.: heart attack, high cholesterol, stroke, arthritis, depression, anemia, asthma, pain, diabetes, etc. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ SURGERIES (include year) e.g.: appendix, tonsils, heart bypass, knee surgery, etc. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ CURRENT MEDICATIONS TAKEN (prescription and over the counter include dose): Drug Name ______________________ Dose ____________ Frequency ______________________ ______________________ ____________ ______________________ ______________________ ____________ ______________________ ______________________ ____________ ______________________ ______________________ ____________ ______________________ ______________________ ____________ ______________________ ______________________ ____________ _______________________ -2Patient Name____________________________________ Date of Birth_________________________ ALLERGIES TO MEDICATIONS: No Yes, please fill in blanks below: Medication:_____________________________ Reaction:___________________________ Medication:_____________________________ Reaction:___________________________ Medication:_____________________________ Reaction:___________________________ OTHER DOCTORS OR SPECIALISTS YOU SEE: Name:______________________ Specialty:__________________ Last Visit:_______ Name:______________________ Specialty:__________________ Last Visit:_______ Name:______________________ Specialty:__________________ Last Visit:_______ Name:______________________ Specialty:__________________ Last Visit:_______ HEALTH MAINTENANCE: When was your last? Physical_________________________ Colonoscopy_____________________ Upper Endoscopy_________________ Cholesterol Blood Test________________ Bone Density Test____________________ Tetanus Shot________________________ Pneumonia Vaccine___________________ Males: Prostate Blood Test (PSA)_______________ Females: PAP/Pelvic Exam____________________ Mammogram___________________ DO YOUR PARENTS OR SIBLINGS HAVE ANY MEDICAL PROBLEMS? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ DO ANY OTHER MEDICAL PROBLEMS RUN IN YOUR FAMILY? e.g. cancer, heart attack, colon cancer, etc. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ DO YOU SMOKE? NO YES FORMERLY Maximum packs per day_______ Number of Years_________ When Quit ________ DO YOU DRINK ALCOHOL? YES NO If yes, how many drinks per week?______________ DO YOU USE ANY OTHER DRUGS? YES NO If yes, what?______________________________ DO YOU HAVE? (circle) LIVING WILL DNR ORDER ADVANCED DIRECTIVES HOW WOULD YOU LIKE TO BE CONTACTED WITH TEST RESULTS, LABS, ETC.? Telephone #___________________________ May we leave a message on a machine? YES NO May we leave a message with a spouse or relative? YES NO Patient Signature________________________________________ OR Guardian Signature_______________________________________ Date___________________ Date____________________ Rev 10/2005 RIMG