01
Personal Information
Patient Demographics
Margaret
Anne
Holloway
Maggie
04 / 22 / 1978
Female
1428 Willowbrook Lane, Apt 3B
Portland, OR 97214
(503) 555-0184
Email
02
Insurance Information
Primary & Secondary Coverage
Blue Cross Blue Shield
XJH 887 442 019
GRP–44218
Margaret A. Holloway
Self
01 / 01 / 2024
None
Pacific Northwest Publishing Co.
I authorize release of medical info to my insurer
I assign benefits directly to Riverside Family Medicine
03
Medical History
Past Conditions & Procedures
Check all conditions you have been diagnosed with
Hypertension
Diabetes (Type I / II)
Asthma
Heart Disease
Stroke / TIA
Cancer
Kidney Disease
Thyroid Disorder
Anxiety / Depression
Arthritis
Migraine
GERD / Ulcers
Surgeries & Hospitalizations
| Year | Procedure or Reason | Facility |
|---|---|---|
| 2019 | Laparoscopic cholecystectomy (gallbladder removal) | Providence St. Vincent Medical Ctr. |
| 2011 | Cesarean section — routine recovery, no complications | Legacy Emanuel Medical Center |
| 2003 | Appendectomy, laparoscopic | OHSU Hospital |
04
Current Medications
Prescription & Over-the-Counter
| Medication | Dosage | Frequency | Reason / Prescribing Physician |
|---|---|---|---|
| Lisinopril | 10 mg | Once daily, AM | Hypertension — Dr. R. Chen |
| Albuterol inhaler | 90 mcg | As needed | Asthma — Dr. R. Chen |
| Sertraline | 50 mg | Once daily, PM | Anxiety — Dr. P. Okafor |
| Vitamin D3 | 2000 IU | Once daily | Supplement, OTC |
| Magnesium glycinate | 400 mg | Nightly | Sleep support, OTC |
05
Allergies & Reactions
Drug, Food, Environmental
Severe
Penicillin
Reaction
Full-body hives, facial swelling, required epinephrine (age 14). Carries EpiPen.
Moderate
Shellfish
Reaction
Oral itching, lip swelling, mild GI distress within 30 minutes of exposure.
Seasonal
Pollen & Dust
Reaction
Rhinitis, watery eyes, worse in spring. Managed with OTC loratadine as needed.
06
Family History
| Relation | Condition | Age |
|---|---|---|
| Father | Coronary artery disease | Dx. 58 |
| Father | Type II diabetes | Dx. 62 |
| Mother | Breast cancer (in remission) | Dx. 54 |
| Maternal grandmother | Osteoporosis | Dx. 68 |
| Brother | Hypertension | Dx. 41 |
| Paternal grandfather | Stroke (fatal) | Age 71 |
07
Emergency Contact
In case of emergency
Contact immediately
Full Name
Thomas J. Holloway
Relationship
Spouse
Years Known
18
Mobile
(503) 555-0267
Alt. Phone
(503) 555-0411
Email
Margaret A. Holloway
Patient Signature
03 / 14 / 2025
Date