Main

★ Register my health history with the Emerald Sands Medical Center.

Español

New in town 3

To make your first appointment, click here.

Please complete our secure online form.

Name: Address:
Date of Birth: Male or Female?: MaleFemale
Home Phone: Work Phone :

Email:

________________________________________________________________________________________
ALLERGIES

What are you allergic to? MedicationsX-ray DyesOther SubstancesNone
If you checked "Medications" please list the name of the medicine and your type of reaction:
Medication 1: Reaction 1:
Medication 2: Reaction 2:
Medication 3: Reaction 3:
If you checked "Other Substances" please list the substance and your reaction:
Substance 1: Reaction 1:
Substance 2: Reaction 2:
Substance 3: Reaction 3:
____________________________________________________________________________________________________

MEDICAL HISTORY AND REVIEW OF SYMPTOMS

Please check problems from the past as well as those you have now:

Abdominal discomfortAlcohol abuseAnemiaAnxietyArthritisAsthma
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Blood disordersBlood in stoolBowels - change in habitsCancerChest pain/chest tightness
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
ColitisConstipationCough - persistentDepressionDiabetesDiarrheaDrug abuse
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Erectile dysfunctionGall bladder diseaseGoutHay feverNeck Pain
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
HeadacheHeart diseaseHemorrhoidsHepatitis or jaundiceHigh blood pressureIndigestion
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Kidney diseaseKidney stonesLight-headedLower back problemsNauseaPalpitationsPneumonia
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Rheumatic feverShort of breathSkin diseaseSwellingThyroid diseaseTuberculosis
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
UlcersUrinating difficultyUrinating frequentlyVenereal diseaseVomitingWeight gain/loss - unexplained
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Other

____________________________________________________________________________________________________
SURGICAL HISTORY
Please list your surgeries:

NON-SURGICAL HOSPITALIZATIONS
Please describe the times you were admitted to a hospital for something other than surgery:

IMMUNIZATION HISTORY
Have you been vaccinated against pneumonia? NoYes -- If "yes" what year?
Have you been vaccinated against hepatitis B? NoYes -- If "yes" what year?
Have you been vaccinated against the flu? NoYes -- If "yes" what year?
Have you been vaccinated against tetanus? NoYes -- If "yes" what year?

Please tell us what other diseases you may have been vaccinated against and when:
1. -- What year?
2. -- What year?
3. -- What year?

___________________________________________________________________________________________________________________________________________________
FAMILY MEDICAL HISTORY

Has any member of your family (including parent, grandparent, or sibling) ever had any of the following?

________________________________________________________________________________________________________________
Cancer NoYes -- Who? parentgrandparentsibling
What type of cancer?
Cancer was diagnosed at what age?
________________________________________________________________________________________________________________
Hypertension (high blood pressure) NoYes -- Who? parentgrandparentsibling
Hypertension was diagnosed at what age?
________________________________________________________________________________________________________________
Heart disease NoYes -- Who? parentgrandparentsibling
Heart disease was diagnosed at what age?
________________________________________________________________________________________________________________
Diabetes NoYes -- Who? parentgrandparentsibling
Diabetes was diagnosed at what age?
________________________________________________________________________________________________________________
Strokes NoYes -- Who? parentgrandparentsibling
Strokes were diagnosed at what age?
________________________________________________________________________________________________________________
Mental disease (anxiety, depression etc) NoYes -- Who? parentgrandparentsibling
Mental disease was diagnosed at what age?
________________________________________________________________________________________________________________
Drug or alcohol addiction NoYes -- Who? parentgrandparentsibling
Addiction was diagnosed at what age?
________________________________________________________________________________________________________________
Glaucoma NoYes -- Who? parentgrandparentsibling
Glaucoma was diagnosed at what age?
________________________________________________________________________________________________________________

Bleeding diseases NoYes -- Who? parentgrandparentsibling
The bleeding disease was diagnosed at what age?
________________________________________________________________________________________________________________
Other NoYes
Describe this "other" health problem in your family history please:

-- Who? parentgrandparentsibling
This problem was diagnosed at what age?
_________________________________________________________________________________________________________________________________________________
MEDICATION

Please list all prescription drugs you take:

Please list all over-the-counter drugs you take:

Please list all vitamins and food supplements you take:

_________________________________________________________________________________________________________________________________________________
PREVENTION

Do you exercise regularly? NoYes
-- If yes..
1) What type of exercise?
2) How many minutes?
3) How many times per week?
Do you smoke? NoYes -- If yes, how many packs per day?
Do you drink alcohol? NoYes -- If yes, how many drinks per day?
Do you drink coffee? NoYes -- If yes, how many cups per day?
Do you drink tea? NoYes -- If yes, how many cups per day?

__________________________________________________________________________________________________________________________________________________
SCREENINGS:

When was your last:
Colon Cancer Test - Year Month
Cholesterol Check - Year Month
Prostate Exam - Year Month

__________________________________________________________________________________________________________________________________________________________
-- MALES PLEASE SCROLL DOWN TO THE "SEND" BUTTON --
__________________________________________________________________________________________________________________________________________________________
(Females) When was your last:

Pap Smear - Year Month
Breast Exam - Year Month
Mammogram - Year Month

__________________________________________________________________________________________________________________________________________________________

(Females) GYNECOLOGIC and OBSTETRIC HISTORY

Your age at your first period: Length of your periods:
Number of ...
Pregnancies: Births: Miscarriages:
(Females) Have you had prolonged or abnormal bleeding?NoYes
(Please describe)

(Females) Have you had leakage of urine? NoYes
(Please describe)

(Females) Have you had pelvic pain? NoYes
(Please describe)

(Females) Have you had abnormal discharge? NoYes
(Please describe)

(Females) Have you had abnormal pap smears? NoYes
(Please describe)

________________________________________________________________________________________________________________

Thank you! To submit your information, please click "SEND."

Comments are closed.