Patient History

Dalip K. Khurana, MD, PLLC

Date: ………………………..Name: ……………………………………………………………..
SS#…………………………..Tel#…………………………….. DOB………………………………………….
Please bring all your medicines, or a list of all your medicines with proper doses, with you when you come

Reason for visit……………………………………………………………………………..

Date of last PAP smear………………..Date of last mammogram………………………….
Date of Colonoscopy………………….Date of Bone density studies………………………
Total number of pregnancies….…..No. of full term births………Pre-term births…………… Stillbirths……Twins/Triplets…….Miscarriages…….Abortions…….Ectopic preg…………
Age at first menstrual period…….…Cycle(Reg/Irreg) ………..Days period lasts…………
Bleeding between periods……………. Date of last menstrual period…………………..….
Contraception/Sterilization………………….Gardasil Vaccination…………………..……
Physically: Very active……… Active ……….. Sedentary ………Inactive…………………
Job: Student…..Retired….. FTEmp….. PTEmp…..UnEmp……. Sexual History…………
Nutrition: Good …..Poor…. Emotional issues…………………… STDs………….………..
Domestic Violence…………..Sexual Abuse………………………Regular Exercise……….…….
Tobacco use………………….Alcohol………………………Drugs……………..……….…
Allergies………………………………………………………………………………………
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Chronic illnesses……………………………………………………………………………..
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List all medications with doses…………………………………………………..………. ….
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Past Hospitalizations………………………………………………………………………….
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Surgeries………………………………………………………………………………………
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Injuries/Accidents……………………………………………………………………………..

Family History: (Mother-M, Father-F, MGM, MGF, Brothers-Bs, Sisters-Ss, Cousins, Maternal Uncle-MU, Maternal Aunts- MAs, Paternal Uncle- PU, Paternal Aunt- PA, Great GPs, etc.)
Asthma…………………………………………………………………………………………
Bleeding disorder………………………………………………………………………………
Cancer…………………………………………………………………………………………. Diabetes………………………………………………………………………………………..
Drug/Alcohol addiction………………………………………………………………………..
Glaucoma………….. ……………………………………………………………………………..
Heart Disease…………………………………………………………………………………..
HTN……………………………………………………………………………………………
Mental illness………………………………………………………………………………….. Stroke…………………………………………………………………………………………..
Other……………………………………………………………………………………………

Your Height: _______ Your Weight._______
Any active problems with your Head…..….Neck…….Eyes…….Ears…..Nose…….Throat……
Skin……..Breasts……….Chest……….Heart……….Lungs……….Abdomen……Extremities……
Genital Organs……..Rectum/Anus……..Urinary system…….Neurological system…………
Muscles……..….Joints..….Psychological system………Endocrine/Hormonal system……..…..