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Patient Medical History

Today’s Date:

Name

Age:

DOB:

Email Address

Home phone number

- -

Work phone number

- -

Cell phone number

- -

How did you hear about us?

Reason for today’s visit

Verification Code :

Current Symptoms/Conditions: (check all that apply)

Seasonal Allergies

Appetite Poor/Changed

Constipation

Night sweats

Decreased libido

Dry skin

Wake up at night

Memory loss

Neurological symptoms

Weight loss

Headaches

Excessive thirst//hunger

Hives/Rashes

Bruise easily

Palpitations

Diarrhea

Insomnia

Sexual dysfunction

Fatigue

Irritability

Mood swings

Skin problems

Difficulty losing weight

Ringing in ears

Vaginal dryness

Swelling of extremities

Anxiety

Bowel habit change

Hot flashes

Joint/Muscle aches

Dry hair

Hair loss

Cravings

Nausea

Weight gain

Wheezing

Numbness/Tingling

Urinating often or at night

Joint pain/stiffness

When did you symptoms start?

What makes your symptoms better?

What makes your symptoms worse?

How long have you had your symptoms?

How would you describe your symptoms? Mild? Moderate? Or Severe?

G.I. Health Related Questions:

Do you experience fatigue and “foggy thinking”?	yes	no
Do you crave sugar; have a bloated abdomen or abdominal pain?	yes	no
Do you have recurrent yeast, vaginal, prostate, or urinary tract infections or rashes?	yes	no
Do you have a white coating on your tongue or inside your mouth?	yes	no
Do you have chronic sinus problems?	yes	no
Do you have itchy rashes on your skin?	yes	no
Do you feel 20 to 30 years older than you really are?	yes	no
Does your long struggle for health cause you depression?	yes	no

Have you been sent home by doctors who say “nothing is wrong with you” when something is obviously wrong?	yes	no
Have you taken repeated or prolonged courses of antibacterial drugs?	yes	no
Are you bothered by hormone disturbances, including PMS, menstrual irregularities, sexual dysfunction, sugar cravings, low body temperature or fatigue?	yes	no
Are you unusually sensitive to tobacco smoke, perfumes, colognes and other chemical odors?	yes	no
Are you bothered by memory or concentration problems? Do you sometimes feel spaced out?	yes	no
Have you taken prolonged courses of prednisone or other steroids for more than 3 years?	yes	no

Do some foods disagree with you or trigger your symptoms?	yes	no
Do you suffer with constipation, diarrhea, bloating, or abdominal pain?	yes	no
Does your skin itch, tingle or burn; or is it unusually dry; or are you bothered by rashes?	yes	no

Allergies:

Medications/Supplements: (please list dosage if possible)

Medical History: (check all that apply):

Abnormal Pap smear	High blood pressure	Stomach/ Bowel problems
Anxiety disorder/Depression	Hormone problems	Stress
Breast problems	High cholesterol	Thyroid disorder
Cancer or tumors	Migraines	Tuberculosis
Cervical problems	Osteoporosis	Endometriosis
Diabetes	Heartburn	Fibroids
Respiratory problems	Prostate Cancer

Other:

Surgical History: Please list all surgeries that you have had since birth. Include the year the surgery was performed:

Family History:

	Cancer	Which family member(s) and what type(s)?
	Diabetes	Family members
	Depression	Family members
	Endometriosis	Family members
	Heart Disease/Problems	Family members
	High Blood pressure	Family members
	Osteoporosis	Family members
	Other	Family members

Women Only:

First day of last menstrual cycle Age first started period

How long do your cycles last?

Do you miss your period or have more than one per month? yes no

no Are your period regular? yes no

Any heavy bleeding ? Any heavy bleeding ? yes no Do you have a history of infertility yes no

Are you on birth control? yes no

If yes, what’s the name/method?

Number of children Number of deliveries

Number of miscarriages Age at onset of menopause:

Have you completed menopause? yes no

Are you pregnant? yes no

Men Only:

Do you have a history of prostate disease? yes no

Have you ever had a elevated PSA? yes no

Do you have history of prostate enlargement? yes no

Do you have a history of prostate cancer? yes no

Do you have urinary frequency? yes no

Social History:

Do you drink alchohol? yes no If yes how often Do you exercise? yes no

How often?

What is your marital status? married single divorced widowed

How many hours of sleep do you get per night Do you take vitamin supplements? yes no

Do you drink caffeine? yes no If yes, how many cups per day? Do you smoke? yes no

If yes, how many

Is there any other information you would like us to know that might impact your health; i.e. recent or past stressors?

Cosmetic Patients Only:

Are you pregnant? yes no Any implantable/permanent makeup? yes no

Have you had Accutane in the last six months? yes no Have you smoked in the last five years? yes no

Do you have any dermal fillers? yes no

Are you currently taking any anti-inflammatory medications (such as Advil, Motrin, or Vioxx)? yes no

Do you have any types of pacemakers/cochlear implants? yes no Do you have any fractured bones? yes no

Have you ever had Botox? yes no

Taylor Medical Group
Eldred B. Taylor, M.D. FACOG
Ava Bell-Taylor, M.D.
5901-C Peachtree-Dunwoody Rd NE
Suite 25
Atlanta, GA 30328
Phone 678-443-4000
Fax: 678-443-4090
www.taylormedicalgroup.net

This information is not meant to diagnose, prevent, treat, cure or mitigate any disease. Please see your doctor about any medical problems or you may use this information in discussion with your doctor.