Name

Have you been to our urgent care before? Yes No

Please tell us what brings you in today and what your symptoms are:

How long have you had these symptoms?

Past Medical History:

Asthma Diabetes Heart disease HIV Depression Anxiety Kidney Disease Schizophrenia

Bleeding disorder Gastrointestinal disease High blood pressure Hypo or hyperthyroidism Substance Addiction COPD STDs Cancer

Other

Please list any surgeries you’ve had:

Height

Weight

Last menstrual period (for women)

Do you take any regular medications?

Medication

Dose

Frequency

Are your immunizations up to date? Yes No

Please list any allergies you have:

Are you a current/former smoker? Yes No

How many packs a day?

When did you start?

When did you stop smoking

Do you drink alcohol?

I don’t drink Social Drinker Daily drinker

Other

Chews tobacco E - cigarettes Marijuana

Medical assistant will fill out this box: