Date: _____________________

COMPLETE & COMPASSIONATE OB/GYN CARE, P.A.
5372 Fredericksburg Rd., Ste. 200 San Antonio, Texas 78229
210-615-6646 (Fax: 210-615-6846)

Instructions: Please print or type all information. All questions must be answered.
There are a total of 5 pages. Click "next" at the bottom of each page.

Name (Last, First, Middle): ________________________________________

Address: ______________________________________________________

Email Address (personal): ___________________ (work): ________________

Home Phone: (____)_______________ Work Phone: (____)______________

Date of Birth: _______________ Place of Birth: ________________________

Race: __________ Height: ______ Weight: ______ Blood Pressure: _________

Marital Status: __ Single   __ Married   __ Divorced   __ Separated   __ Widowed

Present Occupation: ______________________________________________

Highest Grade or Level of Education: _________________________

List ALL drugs, medications, and/or natural supplements you use regularly
(include birth control pills and non-prescription items - laxatives, pain pills, cold tablets, etc.):
____________________________________________________________________

When was your last immunization? (tetnus-lock jaw, diptheria, etc.): _________________
_______________________________________________________________________

PAST MEDICAL HISTORY

Do you have an allergic reaction to any food or drugs? __ Yes  __ No

If YES, list allergies and reactions: ___________________________________________
_______________________________________________________________________

How many times have you been admitted to a hospital: _______
List hospitalizations, starting with most recent: