medicine in balance return visit update form · medicine in balance return visit update form...
TRANSCRIPT
Medicine in Balance Return Visit Update Form
Name__________________________________________________________________
Address________________________________________________________________
_______________________________________________________________________
Telephone: Day_____________________ Cell___________________ Evening__________________________
Email:___________________________________________________ Birthdate: ___________ Age:_________
Spouse / Partner Name______________________________phone:___________________________________
Emergency Contact Name: ___________________________phone:__________________________________
Primary Care Practitioner: ____________________________________________________________________
New Medical Issues Since Last Visit:____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Surgery Since Last Visit:______________________________________________________________________
__________________________________________________________________________________________
Current Medications:________________________________________________________________________
__________________________________________________________________________________________
Current Supplements (please list all, even if we suggested them):____________________________________
__________________________________________________________________________________________
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GYN: last period________________ current birth control method__________________________________
Most recent mammogram/thermogram____________________ Most recent dexa scan_________________
Most recent colonoscopy_________________________ Most recent EKG or Cardiac Calcium Score________
Cigarettes per day:______________ Alcoholic drinks per week:_____________________________________
Recreational drugs per week: (Type?)___________________________________________________________
Reason for Today’s Visit______________________________________________________________________
Comments?________________________________________________________________________________
Signature:_____________________________________ Date: ______________________________________