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Pharmacy Information
Pharmacy Name
Pharmacy Phone
Pharmacy Address
Pharmacy City
Pharmacy State
Pharmacy Zip
*ALLPRESCRIBTIONSNEEDTOBEELECTRONICALLYSENDAFTERJANUARY .1 2022. PLEASE PROVIBE US WITH YOUR PHARMACY*S INFORMATION*
Patient Name
Patient Age
Patient D.O.B
Date
History of Past Illness: Have you Had
Measles
Yes
No
Mumps
Yes
No
Chickenpox
Yes
No
Diabetes
Yes
No
Stroke(s)
Yes
No
Rheumatic Fever
Yes
No
Heart Disease
Yes
No
Tuberculosis
Yes
No
Veneral Disease/STDs
Yes
No
Serious Disease
Yes
No
Ever Hospitalized ?
Yes
No
if yes explain
Ever Had a Surgery ?
Yes
No
if yes explain
Have Had Broken Bones?
Yes
No
if yes explain
Head Concussions or Injuries?
Yes
No
if yes explain
Date of Last Tetanus Shot
Pap Smear (Females)
Mamogram (females)
Family History: Has Anyone in your family ever had?
Cancer
Yes
No
if yes who
Diabetes
Yes
No
if yes who
Tuberculosis
Yes
No
if yes who
Heart Trouble/Disease
Yes
No
if yes who
High Blood Pressure
Yes
No
if yes who
Stroke
Yes
No
if yes who
Convulsions
Yes
No
if yes who
Suicidal Attemtpts
Yes
No
if yes who
Social History
Marital Status
Single
Married
Separated
Divorced
Widowed
Do you Drink Alcohol
Yes
No
if yes, how much
Do you smoke
Yes
No
if yes, how much
Are you Sexualy active?
Yes
No
Highest Education level
What is your Job
Etnicity
American Indian
Asian/Pacific Islander
Black
Latino/Hispanic
White
General Systemic Review
Have you had any recent weight changes?
Yes
No
Have you been in good health most of your life ?
Yes
No
Have you ever had problems with
Skin
Yes
No
if yes explain
Head
Yes
No
if yes explain
Eyes
Yes
No
if yes explain
Ears
Yes
No
if yes explain
Nose
Yes
No
if yes explain
Throat
Yes
No
if yes explain
Neck
Yes
No
if yes explain
Lungs
Yes
No
if yes explain
Heart
Yes
No
if yes explain
Circulatory system
Yes
No
if yes explain
Emotions
Yes
No
if yes explain
Nerves
Yes
No
if yes explain
Muscles
Yes
No
if yes explain
Bones
Yes
No
if yes explain
Stomach
Yes
No
if yes explain
Bowles
Yes
No
if yes explain
Sexual Organs
Yes
No
if yes explain
Urinary Tract
Yes
No
if yes explain
Any Other Problems?
Yes
No
if yes explain
Allergies or reactions to food and/or medications
*YOU MAY BE AT INCREASED RISK FOR TB IF YOU ANSWER YES TO ANY OF THE Following
Date
Do vou have a family member, or close contact with history of confirmed or suspected TB ?
Yes
No
Are you from Asia, Africa, Central America, or South America? (These areas have higher prevalence of TB.)
Yes
No
Do You live in an "out of home" placement facility?
Yes
No
Do you have any history of confirmed or suspected HIV infection?
Yes
No
Do you live with a n individual who is HIV positive?
Yes
No
Have you been or do you live with any individual who has been incarcerate in the last 5 years?
Yes
No
Do you live among, or are you frequently exposed to individuals who are homeless, migrant farm workers, used of street drugs, or residents in a nursing home?
Yes
No
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