John m

John M. McAvoy, M.D., F.A.C.S
Welcome to our office!
Please complete the following prior to you first visit. For the sake of privacy,
many of our patients prefer to download this form and carry it with them to the
office.

Name_______________________________________________
Last First Middle Mr. Mrs. Ms. Dr. Rev.
Preferred Name or nickname______________________
Employer and Employer’s Address _____________________________________________ Referred by_________________Other members of you family in our practice (they will not have any knowledge you were here)_______________________________________________ Friend or neighbor not at your address _________________ Relationship_______________Phone________________________ Spouse or domestic partner: Name______________________ Work phone______________Home Phone_______________ FAMILY HEALTH HISTORY

Mother‘s Age______or Age at death, cause________________
Father’s Age_______or Age at death, cause________________
Health problems, Mother or Father, (include
depression)____________________________________________________________________
Ages and Health of all siblings living or deceased___________________________________________________ Family medical problems: (please circle and list relatives and disease below: Relative Congenital defects: Allergies __________________________________ Death during surgery Mental diseases, depression, suicide or attempts __________________________________ Diabetes __________________________________ Heart disease __________________________________
Seizures __________________________________ HIV, STD YOUR HEALTH HISTORY

Personal physician__________________________________________
Address ___________________________________________
Street City
State Phone Date of: Last physical exam_____________ Mammogram__________ EKG___________ Chest or other X ray ________ menstrual period _______________(YOU CAN NOT HAVE SURGERY IF YOU ARE PREGNANT OR MIGHT BE: A PREGNANCY TEST WILL BE ORDERED UNLESS YOU CAN SIGN THAT YOU ARE CERTAIN YOU ARE NOT PREGNANT) Height __________ Weight____________ Have you gained or lost weight in the past two years________ How much_____ Do you smoke? _________ What? _________ How much? _______ Do you drink alcohol? ______ What? _________ How much? _________ Contact lenses?______ Dentures? ___________ Heart, bone or breast prosthesis? ________________________________________________ Do you take aspirin, herbal or other non-prescription drugs______ Please list ____________________________________________________________________ _____________________________________________________________________________ _____________________________________________ Please list all other prescription or self-administered drugs _____________________________________________________________________________ ALLERGIES: Please circle any: Penicillin Latex Iodine Adhesive tape Sulfa Keflex Aspirin Tetracyclines Sedatives Barbiturates Jewelry Anesthesia Local Anesthesia Agents Other agent or food or drug _____________________________________________________________________________ PRIOR COSMETIC SURGERY: (TYPE & DATES)_______________________________________________________________________ OTHER PRIOR OPERATIONS: (TYPE & DATES) _____________________________________________________________________________ REVIEW OF SYSTEMS CIRCLE ANY THAT YOU HAVE NOW OR IN THE PAST Bleeding Heavy scars or keloid anemia Aids Alcohol abuse artificial joints heart valves asthma Drug abuse Shortness of breath Chest pain Passing out Rheumatic fever Depression Anxiety Attacks Liver disease Kidney Disease Hay fever High blood pressure glaucoma Pacemaker Stroke MI TB Sinus Shingles Hepatitis Herpes HIV STD VD Warts Epilepsy Seizures Other _____________________________________________________________________________ _____________________________________________________________________________ THE ABOVE INFORMATION IS CORRECT , AND I AGREE TO ALLOW DR. McAVOY TO OBTAIN MEDICAL INFORMATION NECESSARY TO MY CARE : (NOTE HERE ANY EXCEPTIONS)_________________________________________

Source: http://www.johnmcavoy.net/wp-content/themes/johnmcavoy01/downloads/NewPatientForm.pdf