PCCS H&PBack to all Forms Patient Name DOB Date Pharmacy Name, City, Cross Roads & Phone Number Past Surgical HistoryType of Surgery Date (MM/YY) Type of Surgery Date (MM/YY) Type of Surgery Date (MM/YY) Type of Surgery Date (MM/YY) Type of Surgery Date (MM/YY) Type of Surgery Date (MM/YY) Past Medical HistoryPlease check any of the following health problems with which you have been diagnosed: Alcoholism Anemia Arthritis Asthma Bleeding Disorder Blood Clots Cancer Cataracts Chemical Dependency Coronary Artery Disease Depression Diabetes Emphysema/COPD Epilepsy/Seizures Gastric Reflux Disease Glaucoma Gout Hepatitis HIV/AIDS High Cholesterol Hypertension Irregular Heartbeat Kidney Stones Migraine Headaches Osteoporosis Pacemaker Pneumonia Prostate Problems Shingles Stroke Suicide Attempt Thyroid Disease Tuberculosis Vascular Disease History of Pain Injury What type of cancer? Other health problems not listed aboveFamily HistoryFather Alive Deceased Medical Problems Mother Alive Deceased Medical Problems Children Alive Deceased Medical Problems Brother Alive Deceased Medical Problems Sister Alive Deceased Medical Problems Maternal Grandmother Alive Deceased Medical Problems Maternal Grandfather Alive Deceased Medical Problems Paternal Grandmother Alive Deceased Medical Problems Paternal Grandfather Alive Deceased Medical Problems Comments Drug Allergies No Known Allergies Yes If yes, list drug allergies AND reactionsMedication ListCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveCurrent MedicationDoseHow oftenHow Many Pills Per Day Add RemoveTobbaco HistoryDo you smoke Cigarettes? Lifetime NON-Smoker Former Smoker Current Everyday Smoker Someday Smoker What (MM/YY) did you Start smoking? What (MM/YY) did you quit? Number of packs PER day? Total of years smoking? Do you smoke Cigars? Yes No How often? Quit Date Do you Vape/Electronic Cigarettes? Yes No How often? Quit Date
