Date of Birth:
Reason for Visit:
Are You a Smoker: Yes No
Do you have asthma?: Yes No
Current Medications and Dosages:
Family History of Medical and Psychiatric Illnesses:
Last Tetanus Shot:
Do you want a flu shot?
When was your last menstrual period?
When was your last pap smear?
When was your last mammogram?
Dr. Kushner is a professor of family Medicine at Midwestern University and teaches medical students and resident physicians. If you object to one of them coming in to the exam room please let the medical assistant know.
1 to 2 Saturdays per month from 9 AM to 12 PM