About Robert Meger, M.D. P.C.

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Contact Information

Patient Title*

Patient Name Preference*

Today's Date*

Patient First Name*

Patient Last Name*

Patient Birthday*

Medical Conditions*

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.”

Previous Surgeries*

Patient Age*

Patient Height*

Patient Weight*

Patient Address*

Street Address Address Line 2 City State ZIP Code

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?*

Medical Information

What procedure would you like a consult for

Are you under the care of a physician now?*

Physician Name

Physician Phone

Last Physical Exam

Are you under the care of a pain doctor?*

If so, what medications are prescribed by your pain doctor?

Do you currently have, or have you ever had any of the following?

Heart Failure*

Hepatitis*

Nervousness / Depression*

Heart Disease / Attack*

Liver Disease*

Psychiatric Treatment*

Chest Pain*

Epilepsy or Seizures*

Multiple Sclerosis*

High Blood Pressure*

Fainting / Dizzy Spells*

Diabetes*

Heart Murmur*

Cancer / Leukemia*

Thyroid Disease*

Mitral Valve Prolapse*

Chemotherapy*

HIV Positive*

Rheumatic Fever*

Glaucoma*

AIDS*

Heart Defects*

Emphysema*

Arthritis*

Scarlet Fever*

Asthma*

Adverse reaction to local anesthetic (Novacaine)*

Artificial Heart Valve*

Difficulties Breathing*

Loss of Appetite*

Heart Pacemaker*

Sinus Trouble*

Loss of Sleep*

Heart Surgery*

Severe Allergies / Hives*

Use a C-pap*

Artificial Joints / Prosthesis*

Yellow Jaundice*

Loud Snoring*

Anemia*

Drug Addiction*

Bruise Easily*

Stroke*

Hemophilia*

(Frequent) Cold Sores*

Kidney Disease*

Sickle Cell Disease*

Latex Allergy*

Are you pregnant or trying to get pregnant?*

Previous Pregnancies*

Number of Children*

Are you currently taking Birth Control Pills?*

Have you ever had a mammogram before?*

Date of your last Mammogram

If you answered “Yes”, please tell us the date of your last mammogram here.

Are you currently taking Blood Thinners?*

Do you smoke?*

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?*

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.