If other, please explain:

Describe previous treatment, if any:

Past History: Name all medications now taken for any reason:

My drug store name:

Drug allergies or sensitivities: List  any drugs or medications to which you are allergic:

Name all previous operations: (with approximate date or year performed):

Comments:

Do you have any other significant illness or medical problem?

Any family members with cancer, diabetes or heart problems?

Last physical exam:

Immunizations up to date? Yes  No

Did you ever use tobacco?  Yes  No    
If yes how much? 

Any Previous significant injuries? When?  (especially to the head, nose, or ear)?

Who referred you for this visit?