Medical History

Name:

Date of Birth:

Reason for Visit:

Are you a smoker:

Yes No

Allergies:

Do you have asthma?

Yes No

Current Medications and Dosages:

Past Illnesses:

Past Surgeries:

Family History of Medical and Psychiatric Illnesses:

Current Symptoms:

Last tetanus shot:

Do you want a flu shot?

Yes No

Women only: When was your last menstrual period?

Last pap smear?

Last mammogram?

Dr. Kushner is a professor of family Medicine at Midwestern University and teaches medical students and resident physicians. If you object to one of them coming in to the exam room please let the medical assistant know.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

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