Please fill out the form below.
1
Page One
2
Page Two
Contact Information
Patient Title
*
- SELECT -
Dr.
Mr.
Ms.
Mrs.
Miss
Patient Name Preference
*
Patient First Name
*
Patient Last Name
*
Patient Birthday
*
Date Format: MM slash DD slash YYYY
Patient Age
*
Patient Height
*
Patient Weight
*
Patient Address
*
Apartment Number
City
*
State
*
ZIP
*
Cell Phone
*
Home Phone
Work Phone
Email
*
Your Occupation
*
Place of Work
*
Insurance Company
Insurance Group Number
Insurance Member ID
How did you hear about our office?
*
- SELECT -
Postcard / Flyer
Realself
Internet Search (Google, Bing, etc.)
Social Media (Facebook, Twitter, YoutTube, etc.)
Yelp
Television
Radio
Newspaper / Magazine
Walk-In / Drive By / Sign
Insurance Company
Festival / Community Event
Friend / Co-Worker / Family
This website
Other
Please help us by telling us how you discovered our practice.
If Friend / Co-Worker / Family, please tell us their name.
If Insurance Company, please name the company.
If Festival or Community Event, which one?
If Other, where?
Medical Information
Purpose of Visit
Please tell us the purpose of your visit today
Are you under the care of a physician now?
*
- SELECT -
Yes
No
Physician Name
Physician Phone
Last Physical Exam
Date Format: MM slash DD slash YYYY
Previous Surgeries
*
Do you currently have, or have you ever had any of the following?
Heart Failure
*
- SELECT -
Yes
No
Hepatitis
*
- SELECT -
Yes
No
Nervousness / Depression
*
- SELECT -
Yes
No
Heart Disease / Attack
*
- SELECT -
Yes
No
Liver Disease
*
- SELECT -
Yes
No
Psychiatric Treatment
*
- SELECT -
Yes
No
Chest Pain
*
- SELECT -
Yes
No
Epilepsy or Seizures
*
- SELECT -
Yes
No
Multiple Sclerosis
*
- SELECT -
Yes
No
High Blood Pressure
*
- SELECT -
Yes
No
Fainting / Dizzy Spells
*
- SELECT -
Yes
No
Diabetes
*
- SELECT -
Yes
No
Heart Murmur
*
- SELECT -
Yes
No
Cancer / Leukemia
*
- SELECT -
Yes
No
Thyroid Disease
*
- SELECT -
Yes
No
Mitral Valve Prolapse
*
- SELECT -
Yes
No
Chemotherapy
*
- SELECT -
Yes
No
HIV Positive
*
- SELECT -
Yes
No
Rheumatic Fever
*
- SELECT -
Yes
No
Glaucoma
*
- SELECT -
Yes
No
AIDS
*
- SELECT -
Yes
No
Heart Defects
*
- SELECT -
Yes
No
Emphysema
*
- SELECT -
Yes
No
Arthritis
*
- SELECT -
Yes
No
Scarlet Fever
*
- SELECT -
Yes
No
Asthma
*
- SELECT -
Yes
No
Adverse reaction to local anesthetic (Novacaine)
*
- SELECT -
Yes
No
Artificial Heart Valve
*
- SELECT -
Yes
No
Difficulties Breathing
*
- SELECT -
Yes
No
Loss of Appetite
*
- SELECT -
Yes
No
Heart Pacemaker
*
- SELECT -
Yes
No
Sinus Trouble
*
- SELECT -
Yes
No
Loss of Sleep
*
- SELECT -
Yes
No
Heart Surgery
*
- SELECT -
Yes
No
Severe Allergies / Hives
*
- SELECT -
Yes
No
Use a C-pap
*
- SELECT -
Yes
No
Artificial Joints / Prosthesis
*
- SELECT -
Yes
No
Yellow Jaundice
*
- SELECT -
Yes
No
Loud Snoring
*
- SELECT -
Yes
No
Anemia
*
- SELECT -
Yes
No
Drug Addiction
*
- SELECT -
Yes
No
Bruise Easily
*
- SELECT -
Yes
No
Stroke
*
- SELECT -
Yes
No
Hemophilia
*
- SELECT -
Yes
No
(Frequent) Cold Sores
*
- SELECT -
Yes
No
Kidney Disease
*
- SELECT -
Yes
No
Sickle Cell Disease
*
- SELECT -
Yes
No
Latex Allergy
*
- SELECT -
Yes
No
Medical Conditions
*
List any and all medical conditions you have.
Medication Allergies
*
List any and all medications that you are knowingly allergic to, or have had an adverse reaction to.
Current Medications
*
Please list ALL medications you are currently taking. If you are not taking any medications at this time, please type "none."
Are you pregnant or trying to get pregnant?
*
- SELECT -
Yes
No
Previous Pregnancies
*
Number of Children
*
Are you currently taking Birth Control Pills?
*
- SELECT -
Yes
No
Are you currently taking Blood Thinners?
*
- SELECT -
Yes
No
Do you smoke?
*
- SELECT -
Yes
No
How many cigarettes a day do you smoke?
*
Because you answered "Yes" above, please tell us here.
Do you use any other nicotine products (Vape, patch, gum, etc.)?
*
Do you use any recreational drugs? If so, which ones, and how frequently do you use them?
*
Is there any other medical information not included above which we should be informed about?
- SELECT -
Yes
No
Additional Medical Information
Because you answered "Yes" above, please tell us here.
Signature of Patient / Parent or Guardian
*
Entering your name above constitutes your signature to proceed.
By entering my name above and checking this box, I consent to give this information.
*
I consent.
Phone
This field is for validation purposes and should be left unchanged.
