Medical History Form - Purely Vasectomies

Patient Name*

First Last

Date of Birth*

Age*

Height*

Weight*

Phone*

Patient's Email*

Patient's Address*

City*

State*

Zip*

Would you like us to send your prescriptions electronically to your pharmacy to be ready for pick up on your way home after surgery?*

Yes
No

Pharmacy Name:*

Pharmacy Address:*

Pharmacy Zip Code*

Are you completing this form for someone else?*

No, I am the patient.
Yes

Relationship to Patient*

INSURANCE AND PRIMARY CARE INFORMATION

Do you Have a Primary Care Provider?*

Yes
No

Provider name/office*

Do you have Medical Insurance?*

Yes
No

Subscriber Name*

First Last

Subscriber Date of Birth*

Subscriber ID Number / Member ID*

Insurance Company Name*

Insurance Company Phone Number*

Insurance Group Number (if applicable)

Employer's Name (if applicable)

MEDICAL INFORMATION

How Many Children Do You Have?*

What Form Of Birth Control or Contraceptive Are You Using?*

Are you taking any prescription or non-prescription medications?*

Yes
No

Please list and explain

Medication	Reason for using medication

Are you presently under the care of a physician?*

Yes
No

For what condition?*

Have you ever been hospitalized or had a serious illness/operation*

Yes
No

For what condition?*

Allergic reaction to any drug, food, or substance*

Yes
No

List*

Cause	Reaction

Have you had abnormal bleeding*

Yes
No

Please explain:*

Do you have any blood disorder such as anemia, hemophilia, sickle cell anemia, HIV*

Yes
No

Please explain:*

Have you ever had treatment for a tumor or cancer*

Yes
No

Please explain:*

Are you taking any blood thinners? (for example aspirin, ibuprofen, Coumadin, Eliquis Plavix, Xarelto)*

Yes
No

Please explain:*

INSURANCE AND PRIMARY CARE INFORMATION

MEDICAL INFORMATION

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING DISEASES, PROBLEMS, OR CONDITIONS

Purely Vasectomies