Home
Cell
Work
If we need to contact you, which is the preferred number?
Can we leave a message at this number on the answering machine?
Are there other members of the household that we may leave the message with regarding your health matters?
If so, whom?
E-mail address (Required Field)
Occupation
Employer
Pharmacy Name
Pharmacy Address
Gender
Race
Other Race
Ethnicity
Primary Preferred Language
Other Language
Primary care Doctor’s Name:
Ear, Nose and Throat:
(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.
If you have a cancer history, please fill out below:
Other Medical History
Do you smoke?
Former smoking date
Do you drink alcohol?
Do you use recreational drugs (Marijuana, Cocaine, Heroin, etc.)?
Diabetes
Heart Disease
Anesthesia Complications
Cancer
Bleeding Disorders
Others
Please list previous surgeries:
Please indicate doses and how often you take.
