Mansfieldkidney.com

Kidney Associates Medical History Form
Please complete entirely and bring to appointment
Name: ____________________________________ Date of Birth: ___________________________
Address: ___________________________________Social Security #_________________________
Phone #____________________________________Cell phone # ___________________________ Emergency Contact Name: ____________________________Phone #________________________ Referring Physician: __________________________ Primary Care Physician: ___________________ Other Specialty Physicians: ___________________________________________________________ Past Medical History:
Please list any medical conditions not listed above: ____________________________________________ ____________________________________________________________________________________ Do you use any nonsteroidal medications such as Celebrex, Mobic, Indocin, Aleve, Motrin, or ibuprofen? If yes, please list medication and how often it is taken __________________________________________ When was the last time the medication was taken? ____________________________________________
Surgical History:
Please list all surgeries: ___________________________________________________
_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Please list any hospitalizations, ultrasounds or CT scans that have occurred within the past year, please include the location.___________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Social History:
Marital Status: _____________________ Occupation: _________________________ Do you currently or have previously used tobacco products? Yes or No Which type of tobacco products do you use and how often do you use them? _____________________________________________________________________ How many years have you used tobacco products? _____________________________ If you are a former tobacco product user, when did you quit? _____________________ How much alcohol do you consume and how often? ____________________________ Do you consume caffeine? Yes or No How much caffeine do you consume on a daily basis? ___________________________
Family History:
Do you have any family members with kidney disease or on dialysis? Yes or No Please list all prescribed medications, over-the-counter medications and
supplements
Please list all medication allergies and the type of reaction: _____________________________ __________________________________________________________________________ __________________________________________________________________________ Pharmacies:
Local pharmacy: _____________________________________________________________
Mail order pharmacy: _________________________________________________________

Please remember to bring your insurance cards along to your
appointment.

Source: http://mansfieldkidney.com/client_files/form/medical-history-form-new.pdf