General Family Practice in St. Petersburg, FL

"I authorize disclosure of necessary medical information to determine benefits payable to related services. By checking YES on this form, I hereby give Labrador Primary Care Center consent to perform medical treatment. If you have a high deductible plan, patient is responsible for payment.”


Alcohol OveruseAllergies (other than medications)ArthritisAsthmaBleeding DisorderCancerCardiac ArrhythmiaChicken PoxColitisDepressionCVA/TIADiabetes Emphysema/COPD FallsGallbladder Disease GoutHIV / AIDSHeart Attack / MI Other Heart Disease(CHF / CAD) HepatitisHigh Blood PressureJaundiceKidney DiseaseMeasles / Mumps

Have you had any of the following illnesses?

Migraine HeadacheNervous BreakdownOstomiesParalysisRheumatic FeverSeizuresSexually Transmitted DiseasesSickle Cell AnemiaSleep DisorderStomach UlcersThyroid DiseaseVascular Disease

Have you ever smoked? YESNO

If yes, are you a regular smoker now? YESNO

Have you used chewing tobacco? YESNO

If yes, number of years. If no, when did you quit?

Do you regularly drink alcohol? YESNO

If yes, how often?

Have you ever used any of the following?


List any operations:

List any serious injuries:

List any hospitalizations (other than surgeries):

Hepatitis B:







Chicken Pox:





Check if any blood relative has or had any of the following:

ArthritisAsthmaBleeding TendencyCancerColitisCongenital Heart DiseaseDiabetesEmphysemaEpilepsyGoiterGoutHay FeverHeart AttackHigh Blood PressureIntestinal PolypsKidney DiseaseLeukemiaMigraineNervous BreakdownRheumatic FeverSickle Cell AnemiaStomach UlcersStrokeSuicideTuberculosisOther

List each medication; its dosage and how often you take it, including vitamins and herbal supplements.

Are you allergic to any medications? If yes, please list medications and the reactions.

Type of Residence:
ApartmentMobile HomeOne Story HomeTwo Story HomeAssisted Living Facility

Durable Medical Equipment:

Can you afford your medications? YESNO

Who provides your transportation?

Do you require assistance to bathe or groom? YESNO

Do you require assistance with your toilet needs? YESNO

Do you require assistance to eat? YESNO

Do you have hearing loss? YESNO

Do you wear hearing aids? YESNO

Last hearing exam date:

Bone Mass Measurement (Density):

Any fractures: YESNO




Do you exercise regularly? YESNO

Have you fallen in the last 12 months?YESNO

Do you frequently lose your balance or feel dizzy? YESNO

Bladder Control Problem? YESNO

Flexible Sigmoidoscopy:

Colonoscopy (not high risk):

Fecal Occult Blood Test:

Hg A1C:

Foot Exam:

Eye Exam:

Cataracts? YESNO

Glaucoma Screening:

Glaucoma? YESNO

Digital Rectal Exam (DRE):

Prostate Specific Antigen Test (PSA):

Mammogram Screening:

Alcohol Screening:

Tobacco Screening:

Pneumonia Vaccine:

Influenza Vaccine:

Sexual History:

Depression Screening:

After you submit your demographics please print and sign the attached forms and bring them with you to your first appointment.