Patient Full Name* First Name, Middle Initial, Last Name
Street Address*Full Street Address or P.O Box
Telephone*Area Code and 7 Digit Number
Date of Birth*
Last 4 Digits of Social Security Number*
Are you Employed?*
Employer's NameIf you are employed please list your major employer's business name.
Employer's Street Address
Zip CodeFive Digit Zip Code
Employer Phone NumberArea Code Plus 7 Digit Number
Type of Position
Full TimePart Time
Retirement DateFill In This Field Only If You Expect To Retire
When Paying Healthcare Bills...How Do You Plan To Pay?*
Responsible Party's InformationFill Out Below If The Patient Is Not The Responsible Party
Person Responsible For Bill
Date of Birth
Street Address or P.O. Box
TelephoneArea Code and 7 Digit Number
Relationship To Patient
Last 4 Digits of Social Security Number
Responsible Party's Occupation
Person To Notify In Case Of An Emergency*Please Type in Full Name, Relationship, Address, Area Code & Telephone Number
Insurance or Medicare/Medicaid Numbers*Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.
Drug Allergies*Please list all drugs and types of reaction
Do you Smoke?*
If so:How many packs? Years Smoking? Have you stopped? Would you like Cessation Education?
Do you use other Tobacco products?*
If so:What product? How long? Have you stopped?
Do you drink Alcohol?*
If so:How long? Last drink? Have you stopped?
Do you use illegal Drugs?*
If yes, what kind?
Do you drink caffeine?*
If yes, how much?
Check All that apply ?
GreatAIDS/HIVArthritisAsthmaBleeding DisorderBowel DiseaseCancerChemical DependencyDepressionDiabetesEpilepsy/ConvulsionsGlaucomaEye DiseaseHeart DiseaseHigh Blood PressureKidney DiseaseLung DiseasePsychiatric CareStrokeThyroid ProblemsTuberculosisOther:
If checked, please indicate the illness and your relationship to the relative.
Check All that apply?
ColitisCirrhosisCrohnsLupus ErythematosusMyastheniaMultiple SclerosisAlcoholismArthritisAsthmaAIDS/HIVAnemiaAnxietyBleeding DisorderBreast MassBronchitisBulimaClotting ProblemsCancerChronic PancreatitisChemical/Drug Dependent
Deep Vein ThrombosisBack PainBlood ClotsBreast CancerColon CancerDepressionDiabetes/Pre-DiabetesEsophageal DysmotilityEmphysemaEpilepsyFibromyalgiaGoiterGonorrheaGoutHeart MurmurHepatitisHerpesImmune System DisorderIrregular Heart BeatGallbladder DiseaseHeart Disease
Irritable BowelHeartburn/RefluxHiatal HerniaHigh Blood PressureHigh ColesterolHigh TriglyceridesHip ProblemsKnee ProblemsAnkle ProblemsFoot ProblemsInfertilityLiver DiseaseKidney DiseaseMigraines/HeadachesPace MakerPneumoniaProstrate ProblemsPsychiatric CarePulmonary EmbolismReaction to AnesthesiaRheumatic FeverSclerodermaSTDPolyscystic Ovarian SyndromeProstrate CancerShortness of Breath w/ExertionSleep ApneaStrokeThyroid DiseaseUrinary Stress IncontinenceUternine CancerVaricose VeinsSeizure DisorderSinus InfectionsSjogrens SyndromeStomach UlcersSuicide AttemptsThyroid ProblemsTuberculosisVaginal InfectionsVenereal DiseaseOther:
Surgical History*Please list all surgical procedures you have had in the past. Include the name/type of operation and the year the procedure was conducted.
Preferred Pharmacy*Please give name, location, and phone number.
Current Medications*List Drug name, dose, frequency, route, and reason for taking. Include Herbal and Over the Counter Medications.
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