Name: Frank Leonard MD
Specialty:
A message to you from Dr. Leonard
If you are a patient new to me and would like to organize your health
history before your visit, please print this web page and complete the
following form to bring with you to your visit. If you prefer not to
complete the form, I will review these items with you at your visit.
It is helpful to bring any medication containers with you, to allow
dosage clarification.
____________________________________________________________
HEALTH HISTORY
Your name__________________________
Medical Conditions:
1._________________________Year began__________
2._________________________Year began__________
3._________________________Year began__________
4._________________________Year began__________
5._________________________Year began__________
Surgeries:
1.______________________________Year___________
2.______________________________Year___________
3.______________________________Year___________
4.______________________________Year___________
5.______________________________Year___________
Medications:
1.____________________Dose__________Frequency__________
2.____________________Dose__________Frequency__________
3.____________________Dose__________Frequency__________
4.____________________Dose__________Frequency__________
5.____________________Dose__________Frequency__________
6.____________________Dose__________Frequency__________
7.____________________Dose__________Frequency__________
8.____________________Dose__________Frequency__________
Medication Allergies:
1.____________________What happened?___________________
2.____________________What happened?___________________
3.____________________What happened?___________________
4.____________________What happened?___________________
5.____________________What happened?___________________
When did you last have the following, if applicable?
Stress Test -
Colonoscopy -
Prostate Specific Antigen -
Pap Smear -
Mammogram -
Bone Density -
Tetanus/diptheria vaccination -
Influenza vaccination -
Pneumovax (pneumococcal pneumonia vaccination) -
Eye examination for glasses or contacts -
Has anyone in your family had the following?
Colon cancer -
Prostate cancer -
Breast cancer -
Coronary heart disease -
High blood pressure -
Diabetes -
Osteoporosis -
Signature_________________________Date__________
____________________________________________________________
Certifications
American Board of Internal Medicine
Currently accepting new patients.
| Offices |
| North Texas Internists, P.A. | Phone: | 214-368-6424 |
| 8335 Walnut Hill Avenue | | |
| Suite 105 | Fax: | 214-360-9012 |
| Dallas, TX 75231 | | |
| |
Admitting Hospitals
Presbyterian Hospital of Dallas
