MLSS EMR (shadow-mode)

Patient Information

Patient Name *DOB *Date *Referring Doctor Family Doctor Reason for visit

Past Medical History

Check all that apply to YOU!

Past Medical History

None

Number of Pregnancies

Number of Births

Asthma

Atrial Fibrillation

Anxiety

Autoimmune Disorder

CVA / Stroke

COPD-Emphysema

Coronary Heart Disease

Crohn's Disease

CRF-Renal Failure

Colon Cancer

Cataract Extraction

Anesthesia Complications

Blood Transfusion

Depression

Diabetes – Type 1

Diabetes – Type 2

GI Bleed

GERD - reflux

Heart Disease

Hyperlipidemia

Hypertension

Hypothyroidism-Underactive

Hyperthyroidism-Overactive

Hepatitis A

Hepatitis B

Hepatitis C

Infertility

Cirrhosis

DVT-blood clots

Kidney Disease

Kidney Stone

Liver Disease

MI-Heart Attack

Neurologic Disorder

Osteoarthritis

Osteoporosis

PVD-arterial disease

PUD – Gastric ulcers

Rheumatoid Arthritis

Skin Cancer

Seizure Disorder

Thyroid Disorder

Tuberculosis

Valvular Heart Disease

UTI – bladder infections

Brain Tumor

Varicose Veins/Phlebitis

Breast Disease

Cervical Cancer

Colon Polyps

Fibromyalgia

Breast Cancer

Prostate Cancer

Other

Past Surgical History

Check all that apply to YOU!

Past Surgical History

Past Family History

Check all that apply to IMMEDIATE FAMILY MEMBERS ONLY! List family member if applicable.

Past Family History

Social History

Circle/Complete all that apply to YOU!

Marital Status

SingleMarriedDivorcedWidow

Living Arrangements

Private ResidenceNursing Home

Any religious beliefs that would affect your care? Type of Work Level of Education

Tobacco

NeverFormerCurrent

Tobacco — packs per day Tobacco — for how long If former tobacco user, how long since you last quit?

Smokeless/Dip/Chew

NeverFormerCurrent

Smokeless — cans per day Smokeless — for how long If former smokeless user, how long since you last quit?

Vape

NeverFormerCurrent

Vape — cartridges per day Vape — for how long If former vape user, how long since you last quit?

Are you exposed to secondhand smoke from someone else in the household?

YESNO

Alcohol

NeverFormerCurrent

Alcohol — drinks per day

Drug use

NeverFormerCurrent

Drug use — substance

Are you at risk for HIV?

YESNO

Regular Exercise

YESNO

Regular Exercise — how many times per week? Date of last Colonoscopy Date of Last Mammogram

Front-Desk Intake — History & Physical

Patient Information

Past Medical History

Past Surgical History

Past Family History

Social History