BASIC INFO

Information provided by:
Relation :
Name :
Information entered by:
Relation :
Name :
Who do we contact in case of an emergency? Emergency Contact:
Contact:
Relationship:
Phone:
Who takes care of the patient?
Parent/Guardian:
Relationship:
Phone:

OR

Caregiver:
Phone :
Height & Weight
Height (Inchs):
Weight (Pounds):

Social history

Race
Ethnicity
Preferred Language :
Have you travelled out the country :
Where :
When :
Advanced Directive Please check ALL that apply:
What is your cigarette smoking status? :
For former smoker
How long you smoked?
when did you quit?
Current Smoker
How long you are smoking:
Averge packes per day :
Are you using or used any other other Tobacco products :
Do you drink beer, wine or liquor? :
No of drinks /week :
Do you have a history of using recreational or street drugs?
Do you have any problems with mobility :
Do you use any assistance device like wheelchair, cane or walker :
Do you have any other special needs :

Medications

Do you take any Over the counter medication/herbal medications :
Medication search :
Duration :
Medication Duration Delete
Fevaba Ambinatime tablete Twise a day
Head achine Ambinatime tablete Twise a day
Do you take any Over the counter medication/herbal medications

Allergies

Do you have any food allergies
Do you have any envioronment Allergies
Are you allergic to Adhesive tape?
Are you allergic to xray dye / Iodine?
Are you allergic to Latex products?
Are you allergic to Eggs
Are you allergic to Shellfish
Do you have any Drug allergies