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Contact Information
Patient Title
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Dr.
Mr.
Ms.
Mrs.
Miss
Patient Name Preference
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Today's Date
*
Patient First Name
*
Patient Last Name
*
Patient Birthday
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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
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Patient Weight
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Patient Address
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Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
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Postcard / Flyer
Realself
Internet Search (Google, Bing, etc.)
Social Media (Facebook, Twitter, YoutTube, etc.)
Yelp
Television
Radio
Newspaper / Magazine
Walk-In / Drive By / Sign
Insurance Company
Festival / Community Event
Friend / Co-Worker / Family
This website
Other
Medical Information
What procedure would you like a consult for
Are you under the care of a physician now?
*
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Yes
No
Physician Name
Physician Phone
Last Physical Exam
Are you under the care of a pain doctor?
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Yes
No
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
*
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Yes
No
Hepatitis
*
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Yes
No
Nervousness / Depression
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Yes
No
Heart Disease / Attack
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Yes
No
Liver Disease
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Yes
No
Psychiatric Treatment
*
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Yes
No
Chest Pain
*
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Yes
No
Epilepsy or Seizures
*
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Yes
No
Multiple Sclerosis
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Yes
No
High Blood Pressure
*
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Yes
No
Fainting / Dizzy Spells
*
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Yes
No
Diabetes
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Yes
No
Heart Murmur
*
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Yes
No
Cancer / Leukemia
*
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Yes
No
Thyroid Disease
*
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Yes
No
Mitral Valve Prolapse
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Yes
No
Chemotherapy
*
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Yes
No
HIV Positive
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Yes
No
Rheumatic Fever
*
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Yes
No
Glaucoma
*
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Yes
No
AIDS
*
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Yes
No
Heart Defects
*
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Yes
No
Emphysema
*
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Yes
No
Arthritis
*
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Yes
No
Scarlet Fever
*
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Yes
No
Asthma
*
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Yes
No
Adverse reaction to local anesthetic (Novacaine)
*
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Yes
No
Artificial Heart Valve
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Yes
No
Difficulties Breathing
*
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Yes
No
Loss of Appetite
*
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Yes
No
Heart Pacemaker
*
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Yes
No
Sinus Trouble
*
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Yes
No
Loss of Sleep
*
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Yes
No
Heart Surgery
*
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Yes
No
Severe Allergies / Hives
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Yes
No
Use a C-pap
*
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Yes
No
Artificial Joints / Prosthesis
*
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Yes
No
Yellow Jaundice
*
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Yes
No
Loud Snoring
*
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Yes
No
Anemia
*
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Yes
No
Drug Addiction
*
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Yes
No
Bruise Easily
*
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Yes
No
Stroke
*
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Yes
No
Hemophilia
*
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Yes
No
(Frequent) Cold Sores
*
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Yes
No
Kidney Disease
*
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Yes
No
Sickle Cell Disease
*
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Yes
No
Latex Allergy
*
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Yes
No
Are you pregnant or trying to get pregnant?
*
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Yes
No
Previous Pregnancies
*
Number of Children
*
Are you currently taking Birth Control Pills?
*
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Yes
No
Have you ever had a mammogram before?
*
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Yes
No
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?
*
– SELECT –
Yes
No
Do you smoke?
*
– SELECT –
Yes
No
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?
*
Is there any other medical information not included above which we should be informed about?
Yes
No
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.
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