Tel: 304. 388. 4965 Fax: 304. 388. 4968
Medical history and physical
1. Patient Name ___________________________________________                                           Age ______ Date of birth ____________     Sex    ___Male  ___Female                                  SSN ___________   Address ________________________     City __________________    State ___  Zip ____________ Home phone _______________________                                 Work Phone ___________________      Cell phone ____________________________         E-mail___________________________________ Spouse or guarantor's name ___________________________________________________________    Employer  __________________________________________________________________________   Primary insurance  ___________________________________________________________________   Secondary insurance  _________________________________________________________________    Referring or family physician's name & address ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 2. Past medical history __ Diabetes Mellitus __ High Cholesterol __ Reflux/Ulcer __ Arthritis __ Hypertension __ Sleep Apnea __ Kidney diseases __ Stress Incontinence __ Heart Disease __ Lung Diseases __ Neurological disease __ Polycystic Ovary __ Stroke __ Asthma __ Cancer __ Depression __ DVT __Pulmonary Embolus __ Hypothyroidism __ Others 3. Past surgical history __________________________________________________________________________ __________________________________________________________________________ 4. Family medical history __Hypertension __Heart diseases __Stroke __ Cancer __ Obesity __ Diabetes 5. Social history __Smoking ____ppd    __Quit  ___ years __Alcohol _____________(frequency)            __Drug use 6. Drug Allergies __No  __Yes: Type:_______________________________________________________________________________ _______________________________________________________________________________________________ 7. Medications _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 8. Review of System __Weight Gain __Headache __Fever __Nausea/vomiting __Freq. urination __Weight Loss __Sore throat __Fatigue __Chest pain __Back pain __Heart attack __Shortness of breath __Cough __Constipation __Joint pain __Palpitation __Heat   intolerance __Dysuria __Black stools __Easy bleeding __Dizziness __Cold intolerance __Coughs __Blood in stools __Skin rash __Blurred Vision __Blackouts __Diarrhea __Abdominal pain __Weakness __Depression __Anxiety __Paralysis __Others:

I hereby authorize Charleston Area Medical Center Weight Loss Center and Dr. Shin to release information regarding my physical condition or

treatments to __________________________________________(insurance companies name(s)).  I also authorize the above insurance

company(s) to pay directly to Dr. Shin all the benefits due me under the above policy numbers by reason of services rendered as provided for

in the above policy(s).  I agree to pay all charges in excess of the amounts paid by the insurance company(s) named above.

Signature:_______________________________________________________  Date:_______________________________