Periodic Visit

Dalip K. Khurana, MD, PLLC

Patient’s Name_______________ Patient’s Date of Birth:____________________

SS#: ________________Tel#:Home:____________Cell:___________________
Please bring all your medicines, or a list of all your medicines with proper doses, with you when you come

Date Today: _________ Reason for visit  today:_________________________

Duration of symptoms:_________Severity of symptoms (On scale of 1-10):_____ Location of problem:_____________________________________________ Frequencyof occurrence:_____________Associated problems:______________  Things that give relief:_______________Things that worsen the problem:______ Reliefs tried so far:_______________________________________________   Date of last menstrual period:____________Contrception:_________________ Allergies:_____________________________________________________ Medications:___________________________________________________

New personal or family history since last visit(Medical/Surgical/Social):__________

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Your Height: _______ Wt._______

Any active problems with:   Head& neck______ Eyes______ Ears_____ Nose_____ Throat______Chest______Cardiac______ Abdomen ______Urinary Tract______  Genital ______Bones/Joints _______ Neurological _______Psychological _______
Endocrine _____Skin _____Breasts_____
Explain: _______________________________________________________
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