Medical History - Hany K. Zaki, MD

Name

First Last

Date of Birth

Sex

Female
Male
Undifferentiated

Allergies

Allergies to Medication X-Ray Dyes

Allergies to Medication X-Ray Dyes
No Known Drug Allergy

List Name of Medication and Reaction?

Past Medical History

Please check off if you have had any problems with or are presently experiencing any of the following

Other - Not Listed Above

Surgery or an Invasive Procedure

No
Yes

Types and Dates

Hospitalizations other than for surgery

No
Yes

Types and Dates

Gynecologic and Obstetric History

Age at onset of periods

Frequency

Length of period

Pregnancies

Births

Miscarriages

Prolonged or Abnormal bleeding

No
Yes

Please Describe

History of abnormal pap smear

No
Yes

Please describe

Immunization History

Hepatitis B

No
Yes

Date*

Pneumovax Immunization

No
Yes

Date*

Covid-19 Immunization*

No
Yes

If not vaccinated please contact the office for further instructions.

First Dose*

Second Dose

Name of Vaccine*

Tetanus Immunization*

No
Yes

Date*

Other Vaccine

No
Yes

Describe

Date

Describe Additional

Last Mammogram

Last Pap Smear

Last Physical Exam

Last Cholesterol Check

Colonoscopy

Last Cholesterol Check

Last Prostate Exam

other

Family History

Has any member of your family (including parents, grandparents and siblings) ever had the following?

Cancer

No
Yes

Describe Type

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Diabetes

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?

Age When Diagnosed

Hypertension (High Blood Pressure)

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Stroke

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Heart Disease

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Mental Disease (Anxiety, Depression, etc...)

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Drug or Alcohol Addiction

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Glaucoma

No
Yes

Family Member?*

Enter 1 For Maternal or Enter 2 For Paternal ?*

Age When Diagnosed

Other Medical Condition Not LIsted

No
Yes

Describe Condition

Family Member?

Enter 1 For Maternal or Enter 2 For Paternal ?

Age When Diagnosed

Medications

Please list below all your Prescription, Over-the-Counter, Vitamins, Herbs, etc...

Name of Medication

Strength/ How often do you take medication

Name of Medication

Strength/ How often do you take medication

Name of Medication

Strength/ How often do you take medication

Name of Medication

Strength/ How often do you take medication

Please list name of Medication MUST include Strength/How often you take your medication

Prevention

Do you wear a seat belt?*

No
Yes

Do you have a smoke detector in your home?*

No
Yes

Do you have a carbon monoxide detector in your home?*

No
Yes

Do you exercise regularly?*

No
Yes

If yes, Type of exercise?

Duration and Number of Times per Week

Do you smoke?*

No
Yes

How many cigarettes per day?*

Fomer smoker?*

No
Yes

How many cigarettes per day?*

When did you stop smoking?*

Do you drink alcohol beverages?*

No
Yes

Type of Alcohol?*

How much per week?*

Formerly drink alcohol ?*

No
Yes

Type of Alcohol?*

How much per week?*

When did you stop drinking*

Do you drink coffee?*

No
Yes

How many cups per day?*

Do you drink tea?*

No
Yes

How many cups per day?*

If there's a gun in your home*

No
Yes

Do you use drugs (marijuana, cocaine, crack, etc...)?*

No
Yes

Describe which one and how often

Do you have an Advance Directive?*

No
Yes