Patient Information Form
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PATIENT INFORMATION
First Name: _________________________________________ MI: ________ Last: _____________________________________ Nick Name: ________________________
Home Phone: ___________________________________ Work Phone: ___________________________________ Cell Phone: ____________________________________
DOB: __________________________________________
K Male
K Female
SS#: ____________________________________________________
Address: ______________________________________________________ City: _____________________________________ State: _________ Zip: _________________
Employer: ___________________________________________________________________________________________________________________________________
State ID/Driver's License #: ______________________________________ E-mail Address: _________________________________________________________________
Name of Physician: __________________________________________________________ Physician Phone: __________________________________________________
In case of Emergency Contact: __________________________________________ Relationship: _________________________ Phone: _____________________________
How did you hear about our office? _________________________________________________________________________________________________________________
Patient Health History
Do you have a history of:
Yes No
Yes No
Yes No
Yes No
A.I.D.S/HIV Positive
Excessive Bleeding
Jaundice
Respiratory Problems/Disorders
K
K
K
K
K
K
K
K
Alcoholism
Epilepsy
Kidney Disease
Rheumatic Fever
K
K
K
K
K
K
K
K
Allergies
Glaucoma
Kidney Dialysis
Rheumatism
K
K
K
K
K
K
K
K
Anemia
K
K
Hay fever
K
K
Latex Sensitivity
K
K
Scarlet Fever
K
K
Arthritis
Head injuries
Lupus
Seizures/Fainting spells
K
K
K
K
K
K
K
K
Asthma
Hearing Impaired
Low Blood Pressure
Sinus Problems
K
K
K
K
K
K
K
K
Blood Disease
Heart Disease
Malignancies
Stomach Ulcers
K
K
K
K
K
K
K
K
Bone Disease
Heart Valve, Murmur
Mitral Valve Prolapse
Stroke
K
K
K
K
K
K
K
K
Cancer
K
K
Hepatitis/Liver Disease
K
K
Neck & Back Problems
K
K
Thyroid Disease
K
K
Chemical Dependency
Type(s) __________
Nervous Problems/Disorders
Tuberculosis
K
K
K
K
K
K
Chest Pain
Hepatitis Carrier
Pacemaker
Tumors or growths
K
K
K
K
K
K
K
K
Circulatory Problems
High Blood Pressure
Prosthetic Joints
Ulcers
K
K
K
K
K
K
K
K
Convulsions/Seizures
Hip or Joint replacement
Psychiatric Care
Venereal Disease
K
K
K
K
K
K
K
K
Diabetes
K
K
HPV
K
K
Radiation Treatment
K
K
Medical Questions
List any medications you are taking including nonprescription drugs:
Do you have any disease/problem you think we should know about? K YES K No
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Are you allergic to any medications? K YES K No If yes, please list below:
____________________________________________________________________
____________________________________________________________________
Have you had a transplant operation that has depressed your immune system?
K YES K No
____________________________________________________________________
Have you had an allergic reaction to Bananas?
K YES K No
Are you in good health?
K YES K No
Do you smoke or chew tobacco?
K YES K No
Date of last medical exam: _____________________________________________
Have you had Heart Surgery?
K YES K No
Have you ever been hospitalized? K YES K No If yes, what was the problem
Are you now under the care of an MD?
K YES K No
____________________________________________________________________
Are you taking or have you ever taken bisphosphonates?
____________________________________________________________________
(Fosamax or Actonel for osteoporosis, chemotherapy, etc)
K YES K No
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Parent category: Medical