Full Legal Name

Residence Address
City, State Zip Code (11111-1111)
Residence Phone
Mobile Phone
Work Phone (with extension)
Email Address
Retaggr Profile Link (digital professional footprint-nice but NOT necessary)

Physicians of Record

Legal Name, Degree Letters (John Smith, MD, JD, HCLD, FACOG)
Specialty (Pulmonary Specialist, Oncologist…)
Address
City, State Zip Code
Phone Number (Office, Home, Mobile on separate lines identified)

Surgical History

1. List by year, earliest to most recent: type of surgery (e.g. 1950:

Tonsillectomy

Past Medical History

1. List by year, earliest to most recent (e.g. 1950: Measles)

Medications

1. List by most frequently used, strength, how often taken, and

importance to you health maintenance (e.g. Vitamin C 500 mg. 1/0
means once a day, AM; 1/1 would mean twice a day, AM and PM)

Vaccination Record

1. List by year and type (e.g. 2009: H1N1)

Allergies

1. List in order of most critical.

2. Be specific and include ALL allergies, both to medicines and non-
medicines. (e.g. penicillin, cats)

Family History

1. Patrilineal
a. Father’s history; if deceased, cause of death
 b. Father’s siblings history; if deceased, cause of death
2. Matrilineal
a. Mother’s history; if deceased, cause of death

Social History

Full Name (Begin with your emergency contact (husband, wife, significant
other, person with whom you reside; if none, skip to your social history)

DOB (date of birth; e.g. 1-10-1967)

Job Title: Supervisor, Kraft Foods, PM Shift

Address
City, State Zip Code

Residence: 888-888-8888
Work: 888-888-8888 Ext. 888
Work Fax: 888-888-8888
Email

Full Name (Patient’s social history)

DOB (date of birth; e.g. 1-10-1967)

Job Title: Supervisor, Kraft Foods, PM Shift

Address
City, State Zip Code

Residence: 888-888-8888
Work: 888-888-8888 Ext. 888
Work Fax: 888-888-8888

Short paragraph here (4-5 typed lines) Indicate where you live (city, rural)
and any significant information regarding pets (domestic and livestock).
Smoking/drinking history, if any, and any eating habits that might impact
medicines or be of general interest to a hematologist.