Prescription Refills and/or Treatment for Minor Ailments

[temporary title for this section]

Statement of security requiring information reentry or land based records verification.

Reason for Visit:

Name Last . M.. First

Patient Telephone Number: Patient Email Address::

Date of Birth

Weight:pounds

Last Blood Pressure / Pulse / Temperature:/

Other Allergies (please list): Type of Reaction:

Current Medications:

Past Medical History

Have you had or do you have any of the following (please check all that apply):

Accidents / Injuries

Operations / Surgery

Asthma / Hay Fever

Rubella

Frequent Colds / Cough

Emphysema / Bronchitis

Hepatitis / Jaundice

Tuberculosis

Positive TB Test

Hepatitis

HIV

Shortness of Breath

Chest Pain / Indigestion

Color Blindness

Heart Trouble

Head / Neck Injury

Backaches / Back Injury

Knee Injury

Bone or Joint Injury

Arthritis / Rheumatism

Kidney / Bladder Trouble

Arteriosclerosis

Swollen Ankles

Depression

Nervous Disorder

Hemorrhoids

Cancer / Tumor

Ulcers

Herpes

Gall Bladder Disease

Hernia Rupture

Diabetes

Thrombophlebitis

High Blood Pressure

Anemia

Hemophilia

Venereal Disease

Frequent Headaches

Trouble Hearing

Double Vision

Do You Wear Prescription Glasses

Goiter or Thyroid Problem

Varicose Veins

Unconsciousness

Mental Illness

Epilepsy / Seizures

Alcoholism

Drug Dependence

Emotional Problems

Blood in the Stool

Sickle Cell Anemia

Erectile Dysfunction

Male Pattern Baldness

Obesity

Other – please list all others:

Women –

Last Menstrual Cycle how often:

how long:

Flow of the Menstrual Cycle (heavy, moderate, light):

Date of Last Period:

Date of Last Pap Smear:

How many times have you been pregnant:

How many deliveries:

How many miscarriages:

Method of Birth Control:

Family Medical History

Please list all medical problems that you are aware of in your relatives:

Father:

Mother:

Sisters:

Brothers:

Others (Cousins, Uncles, Aunts, or Grandparents):

Social History

Do You Smoke:

How many packs a day: How many years:

Do You Drink Alcohol:

How Much: How Often:

Do you do any street drugs:

What, and how often:

Where are you employed:

How long have you been employed:years

What type of work:

Work phone number:

Married / Divorced / Widowed / Single:

Children:

How Many:

Their Ages:

Please list any other information you would like us to know or you think is relevant now:

Please describe your main complaint, with symptoms, with as much detail as possible:

What intervention are you requesting?

(for example, do you request a prescription refill, consultation, advise, or etc.)

Phone number and address of your pharmacy you would like this prescription called in to:

Phone Address

Pharmacy fax number (if available):

Please be advised that any intervention is not a substitute for, nor is it intended to be, a substitute for seeing your personal physician as soon as possible. We recommend that you see your physician as soon as possible.

Physician’s Name:

Telephone Number:

And, again, prior to this section – we’re going to need the disclaimer – before-and-after – any intervention is made. We’re also going to have the same credit card section. And other questions, like, how did they hear about us.

All prescriptions will be called in with date of birth and social security number. I.D. will need to be present at time prescription is picked up.