Spring Hill Primary Care
Name Date
Allergies & Reactions
Name
Dose
Start
End
Prescribed By
Procedure
Year
Where
Physician
Eye Exam
Labs
Colonoscopy
Mammogram
Gynecological Exam
Pap Smear
Last Menstrual Cycle
Pregnancies
Births
Miscarriages
Bone Density
Prostate Exam
Prostate Specific Antigen (PSA)
YesNo
Vaccine
Date
Tetanus
Influenza Vaccine
Zostavax
Shingles
Meningitis
Yellow Fever
Polio
Pneumonia Vaccine
Hep A
Hep B
COVID19 Vaccine
Relation
Details
Mother
Father
Do you smoke? YesNo Years Smoking Packs per Day
YesNo Type BeerWineLiquor Drinks per Week
YesNo Needle Use YesNo
YesNo Number of Partners Partner Gender MaleFemale Birth Control NoneCondomPill/Patch/IUDVasectomyTubal
YesNo Exercise Type Duration
Hours per Night Sleep Problems YesNo
Specialist
Last Visit
Cardiology
Dermatology
Other
Question
Response
Have you had any falls in the past year?
How many falls?
Do you have any fractures due to a fall?
Where are they located?
If you are having pain at this time, what is your pain scale?
1–10
Where is the pain?
Do you use medical equipment supplies at home?
What type of equipment?
Do you have a medical living will?
Do you have a power of attorney?
Who is your power of attorney?
Do you have a hearing problem?
Which ear? LeftRightBoth
Activity
Yes / No
Meal Preparation
Doing Housework
Dressing Yourself
Bathing Yourself
Eating
Walking
Transportation
Have you had any surgeries? Medical History
Today's Date
Patient First Name
Middle Name
Patient Last Name
SR / JR / Other
Preferred Name (if different)
Sex MaleFemale
Date of Birth
Social Security Number Address
Insurance
Member ID #
Home Phone
Cell Phone
Work Phone
Email Address Marital Status MarriedSingleSeparatedDivorcedWidow
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteUnknownOtherRefuse
EnglishSpanishOtherRefuse If Other, please specify
Hispanic or LatinoNon-Hispanic or Non-LatinoUnknownRefuse
Who was your previous medical doctor? Doctor Address Doctor Phone
Name Relationship Address Phone Number
Full Name Signature (Type Name) Date
CURRENT MEDICAL CONDITIONS
1.
2.
3.
4.
5.
PLEASE LIST BELOW IF YOU HAVE ANY OTHER MEDICAL CONDITIONS
ANY QUESTIONS OR CONCERNS FOR DR. KOLLI?
WHAT PHARMACY WOULD YOU LIKE TO USE FOR PRESCRIPTIONS?
(Can be changed at any time)
Name:
Street Address:
City / State / Zip:
Phone Number: