New Patient Form

Please take a few minutes to answer the following questions so we can better assist you with your health care needs. *This form should only be filled out only if you have already scheduled an appointment.

Your Unique Application ID

Address:

City:

State

Zip

Your Email (required)

Home Phone

Cell Phone

Sex:
MF
Date of Birth

Status:

Employer Information

Employer

Business Address

Occupation

Business Phone

Emergency Contact

Name

Relation:

Phone:


When was your last exam? (mm/dd/yyyy)

Physician's Name

Preliminary Health Questions

1. Are you currently under medical treatment?
YesNo
If Yes, please describe

2. Have you ever had any serious illnesses or operations?
YesNo
If Yes, please describe:

3. Are you currently taking any medication?
YesNo
If Yes, describe:

4. Do you smoke?
YesNo
If Yes, how much?

5. Do you use alcohol?
YesNo
If Yes, how much?

6. Do you use any other drugs not prescribed by a physician?
YesNo

7. Have you had any allergic reactions to the following?
Local Anesthetics (eg. Novocaine) YesNo
Penicillin or other antibiotics YesNo
Sulfa Drugs YesNo
Barbiturates (sleeping pills) YesNo
Sedatives YesNo
Iodine YesNo
Aspirin YesNo
Other YesNo
If Yes, what happens?:

Have you ever had the following?

Anemia YesNo
Anorexia (no appetite) YesNo
Arthritis YesNo
Asthma YesNo
Back Problems YesNo
Bleeding Tendency YesNo
Blood Disease YesNo
Cancer YesNo
Chemotherapy YesNo
Chicken Pox YesNo
Chronic Fatigue Syndrome YesNo
Circulatory Problems YesNo
Congenital Heart Lesions YesNo
Cough – persistent or bloody YesNo
Diabetes YesNo
Drug addiction YesNo
Emphysema YesNo
Epilepsy YesNo
Glaucoma YesNo

Heart Disease YesNo
Heart Murmur YesNo
Hepatitis – Type _____ YesNo
Hernia YesNo
Herpes YesNo
High Blood Pressure YesNo
HIV/AIDS YesNo
Jaundice YesNo
Kidney Disease YesNo
Latex Sensitivity YesNo
Liver Disease YesNo
Low Blood Pressure YesNo
Measles YesNo
Migraine Headaches YesNo
Mitral Valve Prolapse YesNo
Multiple Sclerosis YesNo
Mumps YesNo
Pacemaker YesNo
Pneumonia YesNo
Polio YesNo
Prostate Problems YesNo
Psychiatric Care YesNo
Respiratory disease YesNo
Rheumatic Fever YesNo
Scarlet Fever YesNo
Shortness of Breath YesNo
Sinus Trouble YesNo
Skin Rash YesNo
Stroke YesNo
Thyroid Problems YesNo
Tonsillitis YesNo
Tuberculosis YesNo
Ulcer YesNo
Venereal Disease YesNo
Any Other Condition YesNo
Please describe:

Diet (please list a typical day’s diet)








Coffee/Tea/Soda? YesNo
If yes, How many per day:

Water Intake (glasses per day):

Excercise: YesNo
What do you do?

How often /how long do you exercise?

Security

captcha

Yes I certify that the above information is complete to the best of my knowledge and have not knowingly omitted any significant condition/conditions that may be potentially life threatening.