Dr. Kushner
Name:
Date of Birth:
Reason for Visit:
Are You a Smoker: Yes No
Allergies:
Do you have asthma?: Yes No
Current Medications and Dosages:
Past Illnesses:
Past Surgeries:
Family History of Medical and Psychiatric Illnesses:
Current Symptoms:
Last Tetanus Shot:
Do you want a flu shot?
Women Only: When was your last menstrual period?
Women Only: When was your last pap smear?
Women Only: 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.
Marla Kushner, DO