Please fill this sheet out as completely as you can so we have accurate information about our patients. If you are unsure about any of the information asked for, please ask our receptionist or Patient Accountant for help.

Married/Single

Patient’s Name:____________________________M/F______Birthdate:_______Today’s Date:___________

Address:___________________________________________________City:____________________________

State:__________________________________Zip:________________Phone:__________________________

Place of Employment:________________________    Insurance Policy Holder (if different from self):

Daytime Phone: _____________________________    Name: _______________________________________

Social Security #_____________________________   Address: _____________________________________

Insurance___________________________________   City:_____________State:___________Zip_______

Previous Physician___________________________   Phone #: _____________________________________

E-mail Address:______________________________  Birthdate:__________________

               Social Security (if applicable):__________________

Person to contact in emergency:__________________________Relationship to Patient________________

Phone Number of Emergency contact:_________________________________________________________

How did you find our office?  Referred by:__________________Phone Book________Other__________

MEDICAL HISTORY:

List any and/all medications the patient is currently taking :______________________________________

Pharmacy______________________________

Medication/ Food allergies   [  ]        Hospitalizations   [  ]  if  “yes” state when_______________________

Hayfever [ ]

Please check if you have ever had any of the following:

----Immunodeficiency                                                            -----High Blood Pressure

----Cancer (Body Part) ________                                            -----Chest Pain

----Anemia                                                                                 -----Heart Attack

----Low Blood Count                                                               -----Heart Surgery

----Bruise easily                                                                        -----Blood Clot

----Leukemia                                                                             -----Liver Problems

----Prolonged bleeding                                                           -----Hepatitis

----High Cholesterol                                                                -----Ulcers

----Diabetes (Type 1 or 2) ___                                                -----Heartburn

----Thyroid Problems                                                              -----Stomach or bowel surgery

----Gland Surgery                                                                    -----Loss of appetite

----Glaucoma                                                                            -----Difficulty with chewing/swallowing

----Blurred Vision                                                                   -----Persistent Nausea/Vomiting 

----Cataracts                                                                              -----Abdominal pain, Chronic

----Hearing Loss                                                                       -----Gallbladder trouble

----Eye, Ear, Nose or Throat Surgery                                    -----Change in bowel habits

----Nosebleeds                                                                                   -----Constipation

----Sinus Problems                                                                            -----Chronic Diarrhea

----Sore Throat                                                                                    -----Bloody or Tarry stools

----Hoarseness                                                                           -----Kidney Problems

----Asthma                                                                                           -----Kidney Surgery

----COPD/Emphysema                                                             -----Bladder Problems

----Bronchitis                                                                                         ----Incontinence

----Shortness of Breath                                                                        ----Bladder Surgery

----Pneumonia                                                                                       ----Urinating more than 2x/ during night

----Home Oxygen Use  or CPAP/BiPAP  Liters_____         -----Menstrual flow, irregular

      -----Continuously     -----Daytime only    -----Nighttime only     -----Pain/Bleeding with sex

 ---------------------------PAGE TWO--------------------------

-----Prostate problems

-----Decrease in force/flow

-----Arthritis

-----Paralysis

-----Muscle Weakness

-----Joint or Bone surgery                                                                  Menstrual/Pregnancy History:

-----Stroke                                                                                         

-----Seizure/ Epilepsy                                                                         Age at onset of menses __________________

-----Memory Loss                                                                                 First day of last period __________________

-----Dizziness                                                                                       Birth Control Method ___________________

-----Confusion                                                                                      Number of Pregnancies _________________

-----Head Injury                                                                                   Number of Miscarriages _________________

-----Headaches                                                                                     Number of Abortions ____________________

-----Head, neck or back surgery                                                        Number of Live Births ___________________

-----Anxiety                                                                              

-----Depression

-----Eczema                                                                                          Screening Tests:

-----Psoriasis                                                                                       

----Other Rash                                                                                     Date of last Pap _________________________

----Chronic Fatigue                                                                             Previous abnormal Pap __________________

----Weight loss                                                                                    Date of last Mammogram _________________

----Recent Weight Gain                                                                     Date of Bone Density Test _________________

                                                                                                               Date of Colonoscopy ______________________

Family History: List family member if known

                                                                                                               Social History:

----Heart Disease ___________________                                         

----Hay Fever ______________________                                           Relationship Status _______________________

----Cancer  _______________________                                              Occupation _______________________________

----Anemia _______________________                                             Do you exercise, how often _________________

----Bleeds Easily __________________                                             Do you use alcohol ________________________

----Diabetes ______________________                                             How many drinks per day  _________________

----Thyroid _______________________                                             Have you ever used street drugs ____________

----Glaucoma _____________________                                             Do you smoke ____________________________

-----Hypertension _________________                                             How many packs per day ___________________

-----Asthma ______________________                                              How many years have you smoked ___________

----Arthritis ______________________                                              Date you quit smoking ______________________

----Osteoporosis __________________                                              Are you a veteran ___________________________

----Epilepsy ______________________

___Stroke ________________________                                            Past Illnesses:

­­___Migraines _____________________                                            ____Rheumatic Fever             _____Polio

___Alcoholism ____________________                                            ____Scarlet Fever                     _____ Mumps

___Mental Illness __________________                                           ____Chicken Pox/Shingles

I have completed this form entirely and certify that I am the patient or duly authorized agent of the patient  authorized to furnish the information requested.  I understand that even though I have some type of insurance coverage , I am responsible for payment of the service and any interest applied to the unpaid balance.  I also authorize the release of any medical information necessary to process any insurance claim.

Signature___________________________________________________ Office use only ___________________________