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Medicine in Balance Return Visit Update Form Name__________________________________________________________________ Address________________________________________________________________ _______________________________________________________________________ Telephone: Day_____________________ Cell___________________ Evening__________________________ Email:___________________________________________________ Birthdate: ___________ Age:_________ Spouse / Partner Name______________________________phone:___________________________________ Emergency Contact Name: ___________________________phone:__________________________________ Primary Care Practitioner: ____________________________________________________________________ New Medical Issues Since Last Visit:____________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Surgery Since Last Visit:______________________________________________________________________ __________________________________________________________________________________________ Current Medications:________________________________________________________________________ __________________________________________________________________________________________ Current Supplements (please list all, even if we suggested them):____________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ GYN: last period________________ current birth control method__________________________________ Most recent mammogram/thermogram____________________ Most recent dexa scan_________________ Most recent colonoscopy_________________________ Most recent EKG or Cardiac Calcium Score________ Cigarettes per day:______________ Alcoholic drinks per week:_____________________________________ Recreational drugs per week: (Type?)___________________________________________________________ Reason for Today’s Visit______________________________________________________________________ Comments?________________________________________________________________________________ Signature:_____________________________________ Date: ______________________________________
