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Nephrology Associates of Dayton
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Nephrology Associates of Dayton
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Patient History Forms
Patient History Forms
Name
*
Date of Birth
*
Please list any allergies, adverse reactions, or side effects to medications/latex/dyes/shelfish/ect and the type of reaction you have to them
List all medications (including over-the-counter) you are currently taking (Name, Dose, How often)
Pharmacy Name
Pharmacy Location
Diabetes
Yes
No
Year Diagnosed
Kidney Stones
Yes
No
Year Diagnosed
High Blood Pressue
Yes
No
Year Diagnosed
Cancer
Yes
No
Year Diagnosed
Protein in Urine
Yes
No
Year Diagnosed
Thyroid Problems
Yes
No
Year Diagnosed
Blood in Urine
Yes
No
Year Diagnosed
Frequent Urinary Infections
Yes
No
Year Diagnosed
Any other medical issues not mentioned above
List all surgeries that you have had (Type, Location on Body, Year, Surgeon or Facility)
Family (direct blood relatives - Mother, Father, Siblings) Medical History (Relative, Living/Deceased, Age at Death, Health Issues)
Do you, or have you, use tobacco products?
Yes
No
Do you currently used tobacco products?
Yes
No
If you do/did use tobacco, how much per day?
If not currently using tobacco, When did you quit?
Do you currently drink alcoholic beverages?
Yes
No
If yes, How much do you drink per month?
Do you/ Have you use substances or drugs?
Yes
No
If yes, What substances or drugs did you use?
Please list all doctors you visit on a regular basis (Doctors Name, Why you see them, How long?)
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