M.D. CLAIBORNE & ASSOCIATES, L.L.C.

MEDICAL/SOCIAL/FAMILY HISTORY FORM


MEDICAL HISTORY

First & Last Name: 
 
 Drug Allergies: 
 If yes, please list: 
 
 Pharmacy: 
 If other, please name: 
 Pharmacy Telephone Number: 
 
 Are You Currenty Taking Blood Thinners: 
 If yes, please list: 
 
 Name of Primary doctor: 
 Primary Doctor Telephone Number: 

CURRENT AND PAST MEDICAL CONDITIONS AND/OR DISEASES: (PLEASE CHECK ALL THAT APPLY)
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Please list all treating physicians for any conditions checked above:
 
 Name of Primary doctor: 
 Primary Doctor Telephone Number: 

SURGICAL HISTORY

 Reactions to anesthesia (including dental)? 
 If yes, please list symptoms: 
 Past Surgeries? If yes, please list details of any surgeries below: 
 Surgery: 
 Date: 
 Physician Name: 
 Surgery: 
 Date: 
 Physician Name: 
 Surgery: 
 Date: 
 Physician Name: 
 Surgery: 
 Date: 
 Physician Name: 

SOCIAL HISTORY

 Occupation: 
 Years: 
 How many hours per day of sun exposure? 
 How many minutes per day of sun exposure? 
 Do you drink alcohol? 
 If yes, how many drinks per day: 
 Do you smoke? 
 If yes, how many packs per day: 
 Do you use and electronic cigarette? 
 Do you use tanning booths? 
 If yes, what was the last date used: 
 Do you use illegal drugs? 
Any international travel within the last 6 months? 
 Any Exposure to chemicals? 
 If female, are you currently pregnant? 
Are you a vegetarian? 
 Do you currently wear sunscreen? 
What are your hobbies? 

ATTEST & AGREE

By signing this form you attest that all information provided is true and accurate at date listed on this form. Furthermore, by signing this form, you herby release M.D. Claiborne & Associates, LLC from all responsibilities and liabilities whether financial, medial or loss of life associated with treatment and care provided by its physicians and staff based on the information you have listed. We reserve the right to refuse treatment based on any finding of false or inaccurate information contained on this form.
 

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