Important: Please read before filling out this form:

If you have spoken to Dr. Yerby, and been accepted as a new patient, you may proceed with the next step by filling out this health history form.

Please do not fill this out unless you have first been in either email or phone contact with Dr. Yerby. This form is for active new patients, only.

Hit the SUBMIT button only once at the end of the form. The form will be returned by email over a secure server. It is recommended that you print a copy for yourself, as well.

Please be back in touch with Dr. Yerby by phone or email within 24 hours to set up your appointment if this has not already been done. 919-704-6298

Thank you.



 
PATIENT PERSONAL INFORMATION
 
First Name: Last Name:
Street Address: Apartment:
City: State:
Zip Code: Birth Date:
Home Telephone: Work Telephone:
Cell Phone: Email Address:
Sex: Male Female Nick Name:
Marital Status: Employment:
Employer Name:
Student:
School Name:    
PATIENT MEDICAL HISTORY
 
Please list any of the conditions below that your relatives
have and select the person or persons relationship to you.

 
Heart Disease: Yes No
Please list relative or relatives with heart disease (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)


High Blood Pressure: Yes No
Please list relative or relatives with high blood pressure (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Diabetes: Yes No
Please list relative or relatives with high blood pressure (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Kidney Problems: Yes No
Please list relative or relatives with kidney problems (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Cancer: Yes No
Please list relative or relatives with cancer (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Other Condition or Conditions: Yes No

Describe other condition:
Please list relative or relatives with other problems (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)

 

LIST YOUR CURRENT PHYSICIANS
 
Primary Doctor: Specialty:
Doctor: Specialty:
Doctor: Specialty:

 
Enter the date of your last physical exam and the name of the physician who saw you.
 
Date of Last Exam:
Name of Physician:

 
(Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.
 
Date of Last OB/GYN Exam:
Physician:

 
List any medical conditions you have and how long you've had the condition (first month/year diagnosed)
 
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:

Have you ever gone to an emergency room for treatment in the last year? Yes No

 
How many times in the past year?
 
Total number of visits:

 
List the reason and when you made each ER visit.
 
Reason for visit:
Date of visit:
Reason for visit:
Date of visit:
Reason for visit:
Date of visit:

 
Have you ever stayed in the hospital overnight during the past year?
 
Overnight in hospital: Yes No
Number of times in past year:

 
List the reason and the date and when you stayed overnight.
 
Reason:
Date of stay:
Reason:
Date of stay:
Reason:
Date of stay:

 
Have you had surgery?     Yes No

 
List the type of surgery or reason for surgery including dates.
 
Reason for surgery:
Date of surgery:
Reason for surgery:
Date of surgery:
Reason for surgery:
Date of surgery:

 
List any allergies you have to food or medications.

 
Have you ever had an anaphylactic reaction
(turning red, overall swelling, difficulty breathing)?
  Yes No

Do you smoke? Yes No
Select which products you use, how much, and number of years used.

Cigarettes: Yes No
Cigars: Yes No
Pipes: Yes No
Tobacco Chew: Yes No

How much and number of years used:
 
Are you taking any prescription drugs or supplements currently? Yes No

 
List drug or supplement, dosage, and how often you take them.
 
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Please tell us how you would like Dr.Yerby to help you (required):
What is your insurance company, for situations in which we may be able to use it?
 
I request an appointment:

We would greatly appreciate if you would fill out the following.
How did you hear about Dr. Yerby?

How carefully have you read Dr. Yerby's website?

Please call Dr. Yerby within 24 hours of submitting this form to set up your appointment: 919-704-6298