Date:
Social Security Number: Birthdate:

Personal Information
First Name: Middle Initial: Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Sex:
Male
Female
Marital Status:
Minor
Single
Married
Divorced
Widowed
Separated
Domestic Partner

Professional Information
Employer:
Business Phone:
Business Address:
Occupation:
Whom may we thank for referring you:

Emergency Contact
Contact Name:
Phone:
Address:
Do you give our office permission to leave detailed messages regarding your health/lab results?
Yes
No
Specify Numbers:

Primary Insurance:
Phone:
Address:
Subscriber:
Subscriber ID#:
Policy/Group#:


Family History - Please answer all of the following, information will be confidential

Father - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Mother - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Brother 1 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Brother 2 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Brother 3 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Sister 1 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Sister 2 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Sister 3 - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):
Spouse - Age: State of Health:
Name of Disease(if applicable):
Cause of Death:
Year of death (if applicable):


Have any Blood Relatives ever had any of the following?

Blood Disease
Yes
No
If so, who: High Blood Pressure
Yes
No
If so, who: Cancer (where?)
Yes
No
If so, who:
Obesity
Yes
No
If so, who: Epilepsy
Yes
No
If so, who: Kidney Disease
Yes
No
If so, who:
Alchoholism
Yes
No
If so, who: Stroke
Yes
No
If so, who: Gallstones
Yes
No
If so, who:
Sugar Diabetes
Yes
No
If so, who: Heart Disase
Yes
No
If so, who: Tuberculosis
Yes
No
If so, who:

List any other disease that tends to run in your family (Blood Relations):

Surgical History

Name of OperationAgeDateDetails (reason for surgery/complications)
 1   
 2   
 3   


Accidents and Injuries

InjuriesYes/NoAgeDetails (part involved/severity etc)
Broken or cracked bones Yes
No
  
Concussion/head injury Yes
No
  
Back Injury (upper/lower) Yes
No
  
Other Injury Yes
No
  
Ever been advised to have surgery which has not been done?
Yes
No
Explain:
Ever been hospitalized for any other illness not listen above?
Yes
No
Explain:


Other doctors who have treated you in the past

Name and type of doctor Condition treated for Type of treatment Dates
1
2
3
4

Allergies
Are you allergic to any drugs or food?
Yes:
No
if so, which ones:
1 2
3 4

Medications

List all medications or injections and dosages you are on at the present, including those prescribed by a doctor and non-prescription drugs
1 2
3 4
5 6
7 8

Habits

Do youYes/NoPlease Elaborate
Not Get Enough Exercise
Yes
No
Awaken Tired
Yes
No
Sleep Badly
Yes
No
Have irregular bowel movements
Yes
No
Have an unsatisfactory sex life
Yes
No
Hate your work
Yes
No
Have you ever abused alcohol
Yes
No
Have you ever been treated for alcoholism
Yes
No
Have you ever been treated for drug abuse
Yes
No
Get up at night to urinate
Yes
No
Tire or become exhausted easily
Yes
No

Do you or have you ever used:

Yes/NoPlease Elaborate
Laxatives Yes
No
Vitamins Yes
No
Diuretics (water pills) Yes
No
Tranquilizers Yes
No
Sleeping Pills etc Yes
No
Fen/Phen or Redux Yes
No
Cortisone Yes
No
Alcoholic Beverages Yes
No
Coffee Yes
No
Tobacco: cigarettes, cigar, pipe Yes
No
Appetite suppressants Yes
No
Thyroid medication Yes
No

Have you ever taken:

Insulin?
Yes
No
Tablets for Diabetes?
Yes
No


Past Medical History - do you suffer from any of the following?

Addiction:
Yes: No:
Comments:
Alcoholism (Chronic):
Yes: No:
Comments:
Allergy to Drugs:
Yes: No:
Comments:
Anorexia Nervosa:
Yes: No:
Comments:
Anemia:
Yes: No:
Comments:
Arthritis:
Yes: No:
Comments:
Back Ache:
Yes: No:
Comments:
Bleeding:
Yes: No:
Comments:
Bulimia:
Yes: No:
Comments:
Cancer:
Yes: No:
Comments:
Carbohydrate Intolerance:
Yes: No:
Comments:
Chicken Pox:
Yes: No:
Comments:
Colitis:
Yes: No:
Comments:
Diabetes:
Yes: No:
Comments:
Diptheria:
Yes: No:
Comments:
Dysentery:
Yes: No:
Comments:
Eczema:
Yes: No:
Comments:
Eating Disorder:
Yes: No:
Comments:
Epilepsy:
Yes: No:
Comments:
Fainting Spells:
Yes: No:
Comments:
Female Troubles:
Yes: No:
Comments:
Gall Stones:
Yes: No:
Comments:
Goiter:
Yes: No:
Comments:
Gonorrhea:
Yes: No:
Comments:
Gout:
Yes: No:
Comments:
Hair Loss:
Yes: No:
Comments:
Hay Fever:
Yes: No:
Comments:
Head Injury:
Yes: No:
Comments:
Heart Disease:
Yes: No:
Comments:
Hemorrhoids:
Yes: No:
Comments:
Hepatitis:
Yes: No:
Comments:
High Blood Pressure:
Yes: No:
Comments:
Hypoglycemia:
Yes: No:
Comments:
Jaundice:
Yes: No:
Comments:
Kidney Disease:
Yes: No:
Comments:
Liver Disease:
Yes: No:
Comments:
Lung Disease:
Yes: No:
Comments:
Low Blood Pressure:
Yes: No:
Comments:
Migraine:
Yes: No:
Comments:
Mumps:
Yes: No:
Comments:
Nervous Breakdown:
Yes: No:
Comments:
Nervousness:
Yes: No:
Comments:
Neritis:
Yes: No:
Comments:
Osteoporosis:
Yes: No:
Comments:
Pleurisy:
Yes: No:
Comments:
Pneumonia:
Yes: No:
Comments:
Poisoning:
Yes: No:
Comments:
Polio:
Yes: No:
Comments:
Poor Circulation:
Yes: No:
Comments:
Rheumatic Fever:
Yes: No:
Comments:
Rupture/Hernia:
Yes: No:
Comments:
Scarlet Fever:
Yes: No:
Comments:
Sciatica:
Yes: No:
Comments:
Sinus Trouble:
Yes: No:
Comments:
Small Pox:
Yes: No:
Comments:
Stroke:
Yes: No:
Comments:
Syphilis:
Yes: No:
Comments:
Tonsillitis:
Yes: No:
Comments:
Tumors:
Yes: No:
Comments:
Typhoid:
Yes: No:
Comments:
Ulcers:
Yes: No:
Comments:
Varicose Veins:
Yes: No:
Comments:
Whooping Cough:
Yes: No:
Comments:
Any Other Disease:
Yes: No:
Comments:


Do you now have or have you ever had any of the following

Any Eye Disease or eye injury:
Yes: No:
Comments:
Impaired sight:
Yes: No:
Comments:
Any ear disease, Ear injury or impaired hearing:
Yes: No:
Comments:
Any trouble with nose, sinuses:
Yes: No:
Comments:
Any trouble with mouth, throat:
Yes: No:
Comments:
Depression:
Yes: No:
Comments:
Fainting Spells:
Yes: No:
Comments:
Convulsions, Paralysis:
Yes: No:
Comments:
Dizziness:
Yes: No:
Comments:
Headaches, frequent severe:
Yes: No:
Comments:
Leg Cramps:
Yes: No:
Comments:
Enlarged Glands:
Yes: No:
Comments:
Thyroid overactive or underactive:
Yes: No:
Comments:
Skin disease:
Yes: No:
Comments:
Chronic cough:
Yes: No:
Comments:
Chest pain, agina pectoris:
Yes: No:
Comments:
Spitting up blood:
Yes: No:
Comments:
Night sweats:
Yes: No:
Comments:
Shortness of breath, exertion at night:
Yes: No:
Comments:
Palpitations, fluttering heart:
Yes: No:
Comments:
Swelling of hands, feet or ankles:
Yes: No:
Comments:
Vericose Veins:
Yes: No:
Comments:
Extreme tiredness, weakness:
Yes: No:
Comments:
Kidney Disease:
Yes: No:
Comments:
Bladder Disease:
Yes: No:
Comments:
Blood in Urine:
Yes: No:
Comments:
Albumin (sugar, pus in urine):
Yes: No:
Comments:
Difficulty in urination:
Yes: No:
Comments:
Difficulty in reaching erection or orgasm:
Yes: No:
Comments:
Problems with sexual relations:
Yes: No:
Comments:
Abnormal Thirst:
Yes: No:
Comments:
Prostate Trouble:
Yes: No:
Comments:
Ulcer, Bloated feeling after eating:
Yes: No:
Comments:
Indigestion, Gas, Belching:
Yes: No:
Comments:
Appendicitis:
Yes: No:
Comments:
Liver Disease:
Yes: No:
Comments:
Gall Bladder Disease:
Yes: No:
Comments:
Colitis, Other bowel disease:
Yes: No:
Comments:
Hemorrhoids, rectal bleeding:
Yes: No:
Comments:
Costipation:
Yes: No:
Comments:
Diarrhea:
Yes: No:
Comments:
Parasites, worms:
Yes: No:
Comments:
Any Changes in appetite, eating habits:
Yes: No:
Comments:
Any changes in bowel action, stools:
Yes: No:
Comments:
Any other symptoms:
Yes: No:
Comments:


For Women Only - Menstrual History

Age at onset:
Usual duration of period:
Cycle (start to start):
Date of last period:
Children born alive(how many):
Cesarean Sections (how many):
Prematures (how many):
Are you regular, heavy, medium, light:
Do you have tension, depression before period:
Do you have cramps, pain with period:
Do you have hot flashes:
Still Born (how many):
Miscarriages (how many):
Have you ever had ovarian cysts:
Are you taking contraception, what type?: