Full Legal Name Residence Address City, State Zip Code (11111-1111) Residence Phone Mobile Phone

Work Phone (with extension) Email Address Retaggr Profile Link (digital professional footprint-nice but NOT necessary) Physicians of Record Legal Name, Degree Letters (John Smith, MD, JD, HCLD, FACOG) Specialty (Pulmonary Specialist, Oncologist…) Address City, State Zip Code Phone Number (Office, Home, Mobile on separate lines identified) Surgical History 1. List by year, earliest to most recent: type of surgery (e.g. 1950: Tonsillectomy Past Medical History 1. List by year, earliest to most recent (e.g. 1950: Measles) Medications 1. List by most frequently used, strength, how often taken, and importance to you health maintenance (e.g. Vitamin C 500 mg. 1/0 means once a day, AM; 1/1 would mean twice a day, AM and PM) Vaccination Record 1. List by year and type (e.g. 2009: H1N1) Allergies 1. List in order of most critical. 2. Be specific and include ALL allergies, both to medicines and nonmedicines. (e.g. penicillin, cats) Family History 1. Patrilineal a. Father’s history; if deceased, cause of death

b. Father’s siblings history; if deceased, cause of death 2. Matrilineal a. Mother’s history; if deceased, cause of death Social History Full Name (Begin with your emergency contact (husband, wife, significant other, person with whom you reside; if none, skip to your social history) DOB (date of birth; e.g. 1-10-1967) Job Title: Supervisor, Kraft Foods, PM Shift Address City, State Zip Code Residence: 888-888-8888 Work: 888-888-8888 Ext. 888 Work Fax: 888-888-8888 Email Full Name (Patient’s social history) DOB (date of birth; e.g. 1-10-1967) Job Title: Supervisor, Kraft Foods, PM Shift Address City, State Zip Code Residence: 888-888-8888 Work: 888-888-8888 Ext. 888 Work Fax: 888-888-8888 Short paragraph here (4-5 typed lines) Indicate where you live (city, rural) and any significant information regarding pets (domestic and livestock). Smoking/drinking history, if any, and any eating habits that might impact medicines or be of general interest to a hematologist.

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