Kidney Associates Medical History Form
Please complete entirely and bring to appointment
Name: ____________________________________ Date of Birth: ___________________________
Address: ___________________________________Social Security #_________________________
Phone #____________________________________Cell phone # ___________________________ Emergency Contact Name: ____________________________Phone #________________________ Referring Physician: __________________________ Primary Care Physician: ___________________ Other Specialty Physicians: ___________________________________________________________ Past Medical History:
Please list any medical conditions not listed above: ____________________________________________ ____________________________________________________________________________________ Do you use any nonsteroidal medications such as Celebrex, Mobic, Indocin, Aleve, Motrin, or ibuprofen? If yes, please list medication and how often it is taken __________________________________________ When was the last time the medication was taken? ____________________________________________
Surgical History:
Please list all surgeries: ___________________________________________________
_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Please list any hospitalizations, ultrasounds or CT scans that have occurred within the past year, please include the location.___________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Social History:
Marital Status: _____________________ Occupation: _________________________ Do you currently or have previously used tobacco products? Yes or No Which type of tobacco products do you use and how often do you use them? _____________________________________________________________________ How many years have you used tobacco products? _____________________________ If you are a former tobacco product user, when did you quit? _____________________ How much alcohol do you consume and how often? ____________________________ Do you consume caffeine? Yes or No How much caffeine do you consume on a daily basis? ___________________________
Family History:
Do you have any family members with kidney disease or on dialysis? Yes or No Please list all prescribed medications, over-the-counter medications and
Please list all medication allergies and the type of reaction: _____________________________ __________________________________________________________________________ __________________________________________________________________________ Pharmacies:
Local pharmacy: _____________________________________________________________
Mail order pharmacy: _________________________________________________________

Please remember to bring your insurance cards along to your


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This article is reprinted here for the benefit of our clients and their families. We recommend that all of our clients read this article and pass it on to family and friends. Reprinted Article for educational purposes from the New England Journal of Medicine Recently Senator Charles Grassley, ranking Republican on the Senate Finance Committee, has been looking into financial ties between the

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