|How many alcoholic drinks/ day?
Is there a family history (blood relatives only) of the following conditions? If so, circle and write how family member is related to you. (i.e. mother/ father, sister/ brother, grandparent, etc.)
|Are there other diseases/ conditions which run in your family?
MEDICATIONS (please list med name, dose and how often you take it)
DRUG ALLERGIES (please list, if any)
FOR DIABETES PATIENTS ONLY: (skip the rest of this form if you do not have diabetes)
Doylestown Thyroid & Endocrine Associates