Patient Information

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 Operation	Age	Date	Details (reason for surgery/complications)
1
2
3

Accidents and Injuries

Injuries	Yes/No	Age	Details (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 you

Yes/No

Please Elaborate

Not Get Enough Exercise

Yes

Awaken Tired

Yes

Sleep Badly

Yes

Have irregular bowel movements

Yes

Have an unsatisfactory sex life

Yes

Hate your work

Yes

Have you ever abused alcohol

Yes

Have you ever been treated for alcoholism

Yes

Have you ever been treated for drug abuse

Yes

Get up at night to urinate

Yes

Tire or become exhausted easily

Yes

Do you or have you ever used:

	Yes/No	Please 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?: