Please print page and mail the filled out form to the above address.

Name:__________________________________ Date: _______________

IN CASE OF EMERGENCY, CONTACT THE FOLLOWING PERSONS:

Name: _______________________________ Phone #:________________
Relationship:___________________________________________________

PREVENTIVE HEALTH:

Last visit to PCP___________________________
Name of Primary Care Physcian_____________________________
Regular checkups? __________________________
Including Cholesterol screening ____________
Blood pressure screening ___________________
Pap test____________________________________
Mammognam __________________________________
Self-breast Exam____________________________
Prostate screening?_________________________
Regular dental check—ups?___________________

FAMILY HISTORY OF:

Heart disease_______________________________
Relation to Client?_________________________
Cancer______________________________________
Relation to Client?_________________________
Stroke______________________________________
Relation to Client?_________________________

Recent CPR Training ___________ Date:___________

CURRENT MEDICATIONS

Adverse reactions to any medications_________________________________________________________________
____________________________________________________________________________
___________________________________________________________

Allergies:__________________________________________________________________
____________________________________________________________________________
_____________________________________________________________

Frequency and amount of:
Alcohol:_________________________ Smoking:_____________________
Drug Use:______________________________________________

"I authorize Michelle M. Domowicz, M.A. to release information about my care to my primary care physcian.
Clients Signature_______________________Date______________
Witness_______________________________________________"

"I do not authorize Michelle M. Domowicz, M.A. to release information about my care to my primary care physcian.
Clients Signature__________________________Date___________
Witness_______________________________________________"