This form will serve as a dynamic document for patients to continually update and chart their ongoing and changing medical history. The following information is essential for a physician’s staff to provide care in a manner that is compatible with your general health.

This personal health record is provided to you for your convenience only. Entering information into this document does not guarantee that any physician will see it. This form should not be used as a substitute for directly communicating with your physician.

It is important that you provide accurate information so the physician may provide you safe and efficient treatment. Incorrect information can be dangerous to your health. If you have any questions regarding the following information, please consult your physician.

You can print and maintain a paper copy of your personal health record for your files and are strongly encouraged to do so each time you update this record. Neither The Memphis Medical Society, nor any physician affiliated with this organization assumes any liability whatsoever for your personal health record.

Title: _____ First Name: _________________________ Middle Name:__________________

Last Name: ___________________________________ Suffix: _______________________(Jr., Sr., M.D., etc.)

SSN: ______-______-______ Date of Birth: ______ / ______ / ______(mm/dd/yyyy)

Martial Status: _____ Single _____ Married _____ Divorced _____ Widowed

Gender: _____ Male _____ Female

Street Address: ____________________________________________ Apt # _____________

City: ___________________________ State: _______________ Zip ______________

Home Phone: (______) ______ - ______ Work Phone: (______) ______ - ______ ext: _____

Cell Phone: (______) ______ - ______ Email: ______________________________

Occupation: __________________________ Employer: ___________________________

Employer’s Address: ____________________________________________________________

Emergency Contact: __________________________________ Phone: _________________

Who referred you to our Practice ?- ______________________ May we contact them ? _______

Your Doctors’ List (please, fill)

I don’t have a physician (please, circle if true)

Name of Physician: ________________ For care of: ____________ Phone number __________

Name of Physician: ________________ For care of: ____________ Phone number __________

Name of Physician: ________________ For care of: ____________ Phone number __________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

Name: ______________________________ Dosage: ______________ How often: _________

The following is a list of the top twenty (20) medications currently in use in the United States. Please circle ALL of the following that you are taking:

Have you ever had an allergic reaction to any medication? ______ Yes ______No

ACE inhibitors Anticonvulsants Aspirin

Sulfa drugs Other Medication(s) - ____________________________________________________

Have you had any serious illnesses or operations in the last five years? ______ Yes ______No

If yes, please describe and explain: _________________________________________________

______________________________________________________________________________

Have you ever had a blood transfusion? ____ Yes ____No If yes, list dates: ____________

Blood type: (circle one, if known) O+ A+ B+ AB+ O- A- B- AB-

Have you ever had a reaction to local anesthetic? ____ Yes ____ No If yes, please describe:____

Are you pregnant? ______ Yes ______No ______ Maybe Nursing? ______ Yes ______No

Are you taking birth control pills? ______ Yes ______No