Chart#:

Carbondale Family Medicine

Dr. Mukesh Chaudhry, M.D.
1175 Cedar Court Carbondale, IL 62901 Phone: 618-549-0300 Fax: 618-549-0600

MEDICAL INFORMATION Last: DOB: / / 1. 2. 3. Check the symptoms you currently have or have had in the past year: General: Skin: Cardiovascular: Gastrointestinal: First: SS#: Middle: Primary Phone #: ( Date: ) / /

*In consideration of other patients, we ask that your concerns are limited to 3 at todays appointment.

Reason for visit:

Fever Weight Loss Weight Gain Loss of Appetite

Urinary:

Rash Itching Bruise Easily Change in Moles

Gynecology:

Chest Pain Irregular Heart Beat High Blood Pressure

Respiratory:

Heartburn Abdominal Pain Diarrhea Constipation Blood in Stool Nausea/Vomiting Difficult Swallowing

Persistent Cough Coughing Up Blood Shortness of Breath

Blood in Urine Frequency of Urine

Other (Please list):

Irregular Periods Menopause

List any operations you have had:

List any serious illnesses you have had:

Check the diseases you currently have or have had in the past year:

High Blood Pressure High Cholesterol Diabetes

Health Habits: Smoking: packs x day x

Heart Disease Lung Disease Thyroid Disease

Heartburn/Reflux Kidney Disease Liver Disease

drinks x

Other: Other: Other:

day(s) Rec. Drugs:

years Alcohol:

Current - everyday Current - sometime Quit Never

List any allergies you have: ago

Current - everyday Current - sometime Quit Never

ago

Current everyday Current - sometime Quit Never

ago

Chart#:

(If you already have a list of medications already written up, we would be happy to make a copy of it) List all medications, including prescription/non-prescription/OTC/herbal which you are currently taking Medication Dose Frequency

(Additional space):

FAMILY HISTORY Family Member (Place X to signify who has the condition & specify other) grandfather grandmother father mother brother sister son daughter uncle aunt other Illness/Condition High Blood Pressure High Cholesterol Diabetes Heart disease Lung Disease Liver Disease Thyroid Disease Kidney Disease Cancer (list what type) Alcohol/drug abuse Depression/Psychiatric Illness Genetic (inherited) Disorder Other (Additional space):

Have you had: Pneumococcal Vaccine Zostavax Tetnus/TDAP Screening Colonoscopy PSA Screening PAP Smear Mammogram Are you Pregnant? Preferred Pharmacy: Phone: ( ) Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No City: Fax: ( St.: ) When When When When When When When / / / / / / / / / / / / / /

Is there any additional information the doctor or staff should know?:

I certify that above information is correct to best of my knowledge. I understand that neither the doctor nor the office staff is responsible for errors or omission that I have made on this form.
Signature: Print: Date: / /