Paul Bown, MD

CAMC PHYSICIANS GROUP Mark Choueiri, MD, FACS

(304) 388-5120 Office (304) 388-5125 Fax

Please complete each section of this form so that we may serve you better. Do not leave any sections blank.

Name ______Date of Birth ______SS # ______

First Middle Last Name

Age ______Primary Care Physician ______Referring MD ______Other MD______

Reason for today’s visit ______

Are you currently experiencing any problems: (Please Check)

o yes ¨ no Fever, chills, weight loss o yes ¨ no Psychiatric condition

o yes ¨ no Eyes o yes ¨ no Blood and/or Lymphatic problems

o yes ¨ no Ears, Nose, Mouth, Throat o yes ¨ no Seizures/Epilepsy/Strokes

o yes ¨ no Heart or Blood vessel problem o yes ¨ no Skin and/or Breast Lesions or rashes

o yes ¨ no Breathing problems/Asthm a o yes ¨ no Thyroid Disease/ gland problems/Diabetes

o yes ¨ no Stomach or intestinal o yes ¨ no Kidney/Bladder Disease/Infection

¨ yes ¨ no Allergic/Immunologic problems o yes ¨ no Muscle/Bone problems

o yes o no HIV o yes o no Hepatitis

o yes o no TB o yes o no SexuallyTransmitted Diseases

Other Past Medical Problems Not Listed Above______

______

Medication Allergies and Reactions ______

______

Current Medication and Dosage that you take including over the counter medications ______

______

Height ______Weight ______I consider my health as o GOOD o FAIR o POOR Do you use caffeine? o Yes o No Amount ______

Do you smoke? o YES o NO Amount______Chew o Yes o No Amount ______Do you drink alcohol? o YES o NO Amount_____

Did you smoke in the past and quit? o YES o NO How many years did you smoke? ______

Are you pregnant? o Yes o No o Maybe Do you have an Advance Directive/Living Will? o YES o NO

Family history (please check)

Cancer ¨ Yes ¨ No (Who) ______High Blood Pressure ¨ yes ¨ no (Who)______

Diabetes ¨ Yes ¨ No (Who) ______Stroke o Yes o No (Who) ______

Heart ¨ Yes ¨ No (Who) ______Thyroid Disease o Yes o NO (Who) ______

TB o yes o no (Who) ______Liver Disease ¨ Yes ¨ No (Who)______

Psychiatric Care ¨ yes ¨ no (Who)______Melanoma ¨ yes ¨ no (Who)______

¨ Other Chronic Disease ______Who has ______

Signature of patient/Legal Guardian/Responsible Party ______

Date ______Witness ______

Physician’s Signature ______Date ______Time ______