Medical History Form  Today's Date:  * required 1. Name (Last, First):  * required Middle Initial: Date of Birth:  * required 2. Contact Information: Phone Number (including area code):  * required Address:  * required 3. Insurance Information: Please include the following: Primary Insurance Name Group/Plan # Claims Address Policy Holder Please include the following: Secondary Insurance Name Group/Plan # Claims Address Policy Holder 4. Gender:

Male Female

5. Referral Source: a. Did another doctor refer you here? If so, what is his/her name & phone number?

b. Were you referred by a friend or family member? If so, what is his/her name/relation?

6. Do you plan to use Dr. Magid as your Primary Care Physician?

Yes No Undecided 7. Current Medications (Please Include Medication Name, Dose & Number of times each medication is taken daily)

8. Past Surgeries (List All): Please include surgery type, date and surgeon. 9. Past Hospitalizations (List All): Please include hospital, date and reason for hospitalization: 10. Do you have any allergies? If so please list. (Please be sure to indicate if you are allergic to penicillin or sulfur medications): 11. Have you ever had any medical illnesses not previously listed? Please list any/when: 12. Trauma: Have you ever had any major accidents or broken bones? List any injuries/when: 13. Have you ever had any infectious diseases (infectious diseases include, but are not limited to, pneumonia, bronchitis, and urinary tract infections): List Any/When. 14. Immunizations History: (Please indicate if you have been immunized for pneumonia or influenza). List vaccine type/date: 15. Have you ever smoked cigarettes? (Yes/No/Quit) a. If Yes, how many packs per day? How old were you when you started smoking? What is the most you have ever smoked in one day? b. If Quit, when did you quit? How many years did you smoke for? How old were you when you started and when you quit? What is the most you have ever smoked in one day? 16. Do you consume alcohol? (Yes/No/Quit) a. If Yes, how often and what is the maximum quantity? b. If Quit, when did you stop and what was the maximum amount of regular use?  * required 17. Do you have High Blood Pressure? Yes No Unsure 18. Do you have Diabetes?

Yes No Unsure 19. Do you have High Cholesterol? Yes No Unsure 20. Do you have any history of Psychiatric illness/are you being treated with any Psychiatric medications? If so, please describe: 21. Do you have a Family History of Early Coronary Artery Disease? (Yes/No). If you have a father, mother, brother, sister, or child who suffered a heart attack in his/her 40's or 50's.  If Yes, please indicate relation, age at time of heart attack and whether it was fatal. Please list for all family members:   22. Do you have a Family History of Cancer or Tumors? (Yes/No) If Yes, please note relation, age at onset, type of cancer, whether the cancer was successfully treated and if the cancer was fatal. If the cancer was fatal how old was your relative at the time of death. Please include all family members (including yourself). 23. Recent Tests: a. When was your last Blood Work? Include Date/Location and indicate if any abnormalites were detected:  * required b. When was your last Chest X-Ray? Include Date/Location and indicate if any abnormalites were detected:  * required c. Have you had any other tests in the past year? If so, please list and include test type, date and location: 24. Cardiac History: Have you ever had a Stress Nuclear Test, Cardiac Catheterization/Angiogram, STENT placement or Coronary Artery Bypass Graft? If yes, please indicate the test type, date test was performed and what location: 25. Have you had any other tests or procedures that you believe may be useful to your medical evaluation and treatment? If yes, please indicate test/procedure type, date and location: 26. Have you experienced any chest pain, palpitations or shortness of breath? If yes, please describe the symptom (if pain, what type). Indicate frequency, duration and whether the symptoms worsen or only occur during physical activity: 27. Do you experience headaches? (Yes/No). If yes, please describe and list the name of the doctor, if any, that is treating this problem: 28. Do you have any vision problems? (Yes/No) If yes, please describe and list the name of the doctor, if any, treating this problem: 29. Do you have any problems hearing or any regular ear pain or discomfort? (Yes/No). If yes, please describe type of pain, frequency and for how long you have had this problem. 30. Do you experience any regular pain in your neck or throat? (Yes/No). If yes, please describe the type of pain, frequency and how long you have had this problem: 31. Gastro-Intestinal History: a. Do you have any blood in your stool or rectal bleeding? If yes, please list how often and for how long: b. Do you have any regular constipation or diarrhea? If yes, please list how often and for how long: c. Do you have regular stomach pain or bloating? If yes, please list how often and for how long: d. Have you had a recent colonoscopy (within the past 5 years)? If yes, please note the date and what doctor performed the procedure: (Male Patient's Only) e. Have you had a recent prostate/rectal exam (within the past 5 years)? If yes, please note the date and doctor who performed the exam: 32. Do you have any pain or burning during urination, or have you noticed any urinary discomfort or increase in frequency of urination? If yes, please describe the symptom, frequency and for how long you have had this problem: 33. Do you have any known bleeding problems? If yes, please describe: 34. Do you have any other general complaints? (Please list all concerns, including pains, arthritis, swelling or difficulty getting around): 35. Marital Status: Single Married Divorced Widowed If married, indicate for how many years: 36. Do you have any children? If yes, how many and what are their ages?: 37. Do you work? Yes No Retired If yes, what type of work do you do. If retired, what was your former occupation, and for how long have you been retired? 38. Please use the remaining space to share any other information that you believe may be useful to your medical evaluation and treatment: