EFTA00286265.pdf

EFTA00286265 # PRIORITY PRIVATE CARE MAJOR ILLNESSES, HOSPITALIZATIONS & SURGERIES List any of these that you had in the past. Identify these and their associated date(s) 170 East 77th Street, New York, NY 10075 61+6.535.8939 priorityprivatecare.com EFTA00286266 # PRIORITY PRIVATE CARE MEDICATIONS Please list prescriptions and non-prescription medicines, vitamins, herbs, etc. that you take, as well as the dose taken and how many times taken per day. Identify all Prescription Medications you take, dosage and how often (frequency) Identify all Over-the-Counter Medications you take, dosage and how often (frequency). Be sure to include all vitamins 170 East 77th Street, New York, NY 10075 61+6.535.8939 priorityprivatecare.com EFTA00286267 # PRIORITY PRIVATE CARE ALLERGIES Do you have any allergies or known reactions to foods, latex and medications? List all allergies and reactions VACCINATIONS Have you had the following vaccinations? TETANUS K Yes K No If yes, estimated date: HEP A K Yes If yes, estimated date: K No HEP B K Yes If yes, estimated date: K No 170 East 77th Street, New York, NY 10075 646.536.8939 priorityprivatecare.com EFTA00286268 EFTA00286269 II II PRIORITY PRIVATE CARE FAMILY HISTORY Please indicate family members with any of the following conditions: Alcoholism Cancer, specify type Heart disease Anxiety/depression/suicide Blood disorders Genetic disorders Diabetes Kidney disease Anesthesia complications High cholesterol High blood pressure Stroke Lung problems Asthma Alzheimer's disease Other 170 East 77th Street, New York, NY 10075 646.635.8939 priorityprivatecare.com EFTA00286270 EFTA00286271