Patient History Form - Page 2 of 3

P. Anthony Chapdelaine, Jr., MD, MSPH, Founder and Medical Director
General And Alternative Medicine
229 Ward Circle Suite B12
Brentwood, TN 37027
(615) 377-6767

FAMILY HISTORY

For your blood relatives list any of these conditions. If deceased, the cause of death (if known) and age at death. (Examples: Alcoholism, allergies, autism, bleeding, cancer, Crohn’s disease, diabetes, heart disease, high blood pressure, mental disorders, osteoarthritis, rheumatoid arthritis, stroke, thyroid disease, tuberculosis)

Father_________________________________________________________________________
Mother ________________________________________________________________________
Brothers/sisters_________________________________________________________________

MEDICATION & VITAMINS or SUPPLEMENTS

List any prescription (or over-the-counter) medication you are now using (or are supposed to be using

List vitamins and supplements you take regularly

List any known drug allergies and your reaction to the drug
______________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________

 
How often do you drink the following (never, occasionally, daily, weekly etc.)

Regular soft drinks _________  Diet soft drinks__________
Cups or glasses regular/black tea _________
Cups of regular coffee ________ 
Other beverages (list) ________________________

HABITS and EXPOSURES

Have you ever smoked cigarettes/used tobacco? ________
If yes, are you smoking now? _______ How many? ________
Alcohol (indicate daily or monthly)________
Exercise (Daily Weekly Occasionally Never)? _________ What type exercise? ___________________
Do you have constipation or diarrhea or abdominal bloating? (Which?) _________________________