Today’s Date: YYYY-MM-DD format

GENERAL INFORMATION

First Name:

MI:

Last Name:

Social Security Number:

Date of Birth: YYYY-MM-DD format

Address 1:

Address 2:

City:

State:

Zipcode:

Phone Numbers

Home:

Cell:

Work:

E-mail address

If we need to contact you, which is the preferred number?

HomeCellWork

Can we leave a message at this number on the answering machine?

YesNo

Are there other members of the household that we may leave the message with regarding your health matters?

YesNo


If so whom?

E-mail address (Required Field)

Occupation:

Employer:

Preferred Pharmacy

Pharmacy Name:

Pharmacy Address:

Government regulations require we ask for the following identifying information.

Gender: FemaleMale

Race: CaucasianAfrican AmericanAmerican Indian/Alaska NativeAsian

Other Race:

Ethnicity: Non-HispanicHispanic

Primary Preferred Language: EnglishSpanish

Other Language:

How did you hear about our practice?

Physician Referral
Doctor’s Name:


Friends / Family
Whom may we thank?

Web SearchSocial Media
Other:


Primary care Doctor’s Name:

ADULT REVIEW OF SYSTEMS

Ear, Nose and Throat:

Decreased HearingRinging in EarsDizzinessPressure in EarsNoise ExposureSore ThroatSwollen GlandsHoarseness / Voice ChangeDifficulty SwallowingNose Bleeds

PAST MEDICAL HISTORY

(Please check the symptoms below to indicate.)
Indicate if you have any of the medical problems listed below and add any additional problems not covered in the space provided.

High Blood PressureCoronary Artery DiseaseAngina (Chest Pain)High CholesterolAsthmaEmphysema / COPDHeartburn / GERDKidney / Renal DiseaseArthritisDiabetesThyroid ProblemsDepressionAnxietyBleeding DisorderHistory of Clots in Lungs / LegsHistory of TMJ DysfunctionHistory of Migraine HeadachesImmune DeficiencyStroke / CVAAutoimmune Disease (Rheumatoid, Lupus, Hashimotos, etc.)History of CancerOther

If you have a cancer history, please fill out below:

Other Medical History:

SOCIAL HISTORY:
Do you smoke?
YesNoFormer smoker


Former smoking date:

Do you drink alcohol?
YesNo


If yes, how much?
1-3 drinks/week4-10 drinks/week10+ drinks/week


Do you use recreational drugs (Marijuana, Cocaine, Heroin, etc.)? NoYes

FAMILY HISTORY:

Do any of these diseases run in your family:

Diabetes MaternalPaternal side


Heart Disease MaternalPaternal side


Anesthesia Complications MaternalPaternal side


Cancer MaternalPaternal side


Bleeding Disorders MaternalPaternal side

Others

PAST SURGICAL HISTORY

Please list previous surgeries:

CURRENT MEDICATIONS

Please indicate doses and how often you take.

ALLERGIES TO MEDICATIONS