About You

Today Date:
File #:
Patient Name:
What you Prefer to be Called:
Male
Female
Birth date:
Age:
SS#:
Mailing Address:
City Add:
State:
Zip Code:
Home No. :
Work No. :
Cell No. :
Email Address:
Referred By:
Employer:
How Long?
Employer's Address:
City Add:
State:
Zip Code:
Occupation:
Spouse's Name:
Status:
Minor
Single
Married
Divorced
Windowed
Separated
Do you have childrens?
Yes
No
How many?

Insurance Info

CO. Name:
Address:
City:
State:
Zip Code:
Phone #:
Insured's ID#:
Group #:
Insured's Name:
Relation:
Date of Birth:
Relation:
Billing Address:
City Add:
State:
Zip Code:
SS #:
Drivers Licence #:
Work Phone #:

Medical Info

Reason For today's Visit ?
What Medication are you taking ?
Nerve Pills Pain Killer Muscle relaxer
Stimulants Blood Thinner Transquilizer
Insulin Meds for osteoporosis Others
Do you have or have you had any of the following diseases, medical conditions or procedures ?
Heart problems Mitral Valve Prolapse Jaw Problem TMJ/TMD Recently Hospitalized hingles
Kidney problems Herpes/Fever Blisters Cancer/Tumors Fainting/Seizures/Epilepsy Diabetes/Hypoglycemia
Venereal Disease Respiratory Problems Hepatitis Back/Neck Problems Leukemia
Liver Problems Sinus Problems HIV+/AIDS/ARC Xray or Cobalt Treatments Anemia
Tubercutosis TB Digestive Problems/Ulcers Arthritis/Rheumatism Chemotherapy Bleeding Problems
Thyroid problem Rheumatic/Scarlet Fever Artificial Bones/Joints/Implants Lupus High/Low blood Pressure
List any Others. Procedure conditions or surgeries you have or ever had ?
are you allergic to any of the following?
Latex
Pencilin
Tetracyclin
Aspirin
Anesthetic
Foods: Others:
Do you use Tobacco? Yes No
How used? How much? How long?
Emerg Contact No #:
Phone #:
Cell #:
Primary Physician:
Phone #:
Cell #:
Women: Taking birth control? Yes No Are you Nursing: Yes No How long?