Email: [email protected]

Web: https://quickprimarycare.org/

Quick Primary Care

8550 SW State Road 200
Ocala, FL 34481

Phone: 352-854-9110

Fax: 352-854-9119

QPC New Patient - Page 4

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Quick Primary Care

Medical History - Page 4 of 9

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Medical History

Check all that apply for you (Self) and your immediate family.

Family medical history

Desc.	Self	Father	Mother	Brother	Sister
ANEMIA / BLOOD
ARTHRITIS / BONE
ASTHMA
CANCER
DIABETES
EMPHYSEMA
EPILEPSY
GLAUCOMA
HEART DISEASE / ATTACK
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
KIDNEY / BLADDER DISEASE
LIVER DISEASE / HEPATITIS
MENTAL ILLNESS
OBESITY
STROKE
THYROID
TUBERCULOSIS
ULCER / STOMACH
VENEREAL DISEASE
VISUAL IMPAIRMENT / BLIND
HEARING LOSS
HIV / AIDS
DRUG ADDICTION
ALCOHOLISM
ALLERGIES
HAY FEVER / SINUS
SKIN PROBLEMS
ABDOMINAL PAIN
BACK PAIN
CHEST PAIN
JOINT PAIN
LEG PAIN
NECK PAIN
SHORTNESS OF BREATH
DIZZINESS / FAINTING
HEADACHES
NUMBNESS / TINGLING
WEAKNESS
FATIGUE
WEIGHT LOSS
SLEEP PROBLEMS
DEPRESSION / ANXIETY
MEMORY LOSS
OTHER

Other Info

OTHER (please describe)

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