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

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Contact Information
Patient Title*
Patient Name Preference*
Today's Date*
Date Format: MM slash DD slash YYYY
Patient First Name*
Patient Last Name*
Patient Birthday*
Date Format: MM slash DD slash YYYY
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
Purpose of Visit
Please tell us the purpose of your visit today
Are you under the care of a physician now?*
Physician Name
Physician Phone
Last Physical Exam
Previous Surgeries*
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*
Medical Conditions*
List any and all medical conditions you have.
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.”
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
Date Format: MM slash DD slash YYYY

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.

Actual Patient of Dr. Meger

New Patient Form

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New Patient Form

Please fill out the form below.

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Contact Information

Medical Information

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

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