Last Name:

First Name:

Middle Initial:

Street Address:

City:

State

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Patient's Employer:

Employer's Address:

Employer's City:

Employer's State:

Employer's Zip:

Occupation:

Purpose of visit:

How did you hear about us?

Referred by:

Date of Birth:

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Family

Spouse/Legal Guardian:

Relationship to Patient:

Spouse/Guardian Employer:

Phone of Employer:

Employer Street Address:

Employer City:

Employer State:

Employer Zip:

Primary Insurance:

Address:

City:

State:

Zip:

Name of Insured:

Insured's ID Number:

Group Plan Number:

Height:

Weight:

Past Medical History: Have you had anything other than the usual childhood diseases?

Is the patient a smoker?

Medications:

Drug Allergies:

Previous Surgeries and Approximate Year:

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In the past few months, have you had –

H & N -
Any eye disease, faulty sight, or eye pain?	Yes No
Any ear disease, impaired hearing?	Yes No
Any trouble with nose, sinuses, mouth, or throat?	Yes No
Hard lumps on tongue, lips or mouth?	Yes No
Glaucoma?	Yes No
CVR -
Chronic/frequent cough?	Yes No
Chest pain or angina pectoris?	Yes No
Spitting up of blood?	Yes No
Night sweats, chills, fever?	Yes No
Shortness of breath?	Yes No
Wake up short of breath?	Yes No
Palpitation or fluttering of heart?	Yes No
Swelling of hands, feet or ankles?	Yes No
Rheumatic fever?	Yes No
Tuberculosis?	Yes No
High or low blood pressure?	Yes No
Heart murmur?	Yes No
Heart attack?	Yes No
GI -
Stomach trouble, ulcer or pain?	Yes No
Indigestion, vomiting or nausea?	Yes No
Liver or gallbladder disease?	Yes No
Any black bowel movements?	Yes No
Constipation or diarrhea?	Yes No
Recent change in bowel action or stools?	Yes No
Cirrhosis of liver?	Yes No
Jaundice (yellow)?	Yes No
GU -
Kidney disease or stone?	Yes No
Bladder disease?	Yes No
Albumin, sugar, pus or blood in urine?	Yes No
Difficulty controlling urination?	Yes No
ENDO -
Abnormal thirst?	Yes No
Diabetes?	Yes No
Thyroid disease?	Yes No
Any diabetes in family?	Yes No
List:
HEMO -
Anemia (low blood)?	Yes No
Do you bleed or bruise easily?	Yes No
Any unusual bleeding after surgery or dental work?	Yes No
Any family member a free bleeder?	Yes No
If yes, please specify:
NEURO -
Fainting Spells?	Yes No
Loss of consciousness?	Yes No
Convulsions/epilepsy?	Yes No
Paralysis attacks?	Yes No
Dizziness?	Yes No
Often or severe headaches?	Yes No
Migraine Headaches?	Yes No
Nervous breakdown?	Yes No
PREGNANCIES –
Total number?
How many children born alive?
Are you, or might you be pregnant now?	Yes No
Any female trouble now?	Yes No
TOBACCO -
Cigarettes?	Yes No
Packs per day?