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?