Paul R. Young, M.D. PLLC | Adult Registration 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