Patient Information

Date

Insurance Information

Primary Insurance Company Name

Address

City/State

Zip

Phone #

Insured Name

Date Of Birth

Employer

Contract #

Group #

Secondary Insurance Company Name

Address

City/State

Zip

Phone #

Insured Name

Date Of Birth

Employer

Contract #

Group #

Patient Name

Date Of Birth

Please List All Medications You Are Currently Taking (Include Prescriptions, Over-The-Counter Meds and Herbal Supplements)

Name

Dose

How Often Do You Take It

Name

Dose

How Often Do You Take It

Please List All Prior Surgeries

Type of Surgery

Date

Type of Surgery

Date

Type of Surgery

Date

Type of Surgery

Date

Please List All Prior Hospitalizations (Other Than For Surgery)

Reason for Hospitalization

Date

Reason for Hospitalization

Date

Reason for Hospitalization

Date

Reason for Hospitalization

Date

Social History

Employer

Occupation

How Much Are You On Your Feet At Work?

10% 25% 50% 75% 100%

Do Others Depend Upon You For Their Care?

Children- Age(s) Pet(s) -

Exercise:

Never Rare Occasional Weekly Several Times a Week Daily

Type of Exercise

Family History

Do You Have a Family History Of

Diabetes Cancer Heart Disease High Blood Pressure Stroke Coronary Artery Disease Thyroid Disease Rheumatoid Arthritis Other

Patient Name

Date of Birth

Your Medical History

Allergies

None Known Medications Anesthesia Foods Tape Latex Shellfish Iodine Other

Have You Ever Had Any Of The Following?

ACID REFLUX	Y	N	FIBROMYALGIA	Y	N	NEUROPATHY	Y	N
ANEMIA	Y	N	GOUT	Y	N	OPEN SORES	Y	N
ARTHRITIS	Y	N	HEART ATTACK	Y	N	PNEUMONIA	Y	N
ASTHMA	Y	N	HEART DISEASE/ FAILURE	Y	N	POLIO	Y	N
BACK TROUBLE	Y	N	HEPATITIS	Y	N	RHEUMATIC FEVER	Y	N
BLADDER INFECTIONS	Y	N	HIV+AIDS	Y	N	SICKLE CELL DISEASE	Y	N
ABNORMAL BLEEDING	Y	N	HIGH BLOOD PRESSURE	Y	N	SKIN DISORDER	Y	N
BLOOD CLOTS	Y	N	KIDNEY DISEASE	Y	N	SLEEP APNEA	Y	N
BLOOD TRANSFUSION	Y	N	LIVER DISEASE	Y	N	STOMACH ULCERS	Y	N
BRONCHITIS/EMPHYSEMA	Y	N	LOW BLOOD PRESSURE	Y	N	STROKE	Y	N
CANCER	Y	N	MIGRANE HEADACHE	Y	N	THRYOID DISEASE	Y	N
DIABETES	Y	N	MITRAL VALVE PROLAPSE	Y	N	TUBERCULOSIS	Y	N

How Long Ago Did This Problem Start? Days Weeks Months Years

Did Your Pain Or Problem

Begin All Of A Sudden? Gradually Develop Over Time?

How Would You Describe Your Pain?

No Pain Sharp Dull Aching Burning Radiating Itching Stabbing Other:

Since The Time Your Pain Or Problem Began, Has It

Stayed The Same Become Worse Improved

What Makes Your Pain Or Problem Feel Better?

What Treatments Have You Had For This Problem?

How Has This Problem Affected Your LifeStyle Or Ability To Work?

Was This Problem Caused By An Injury?

Yes ( Describe ) No

If Yes, Was It A Work- Related Injury?

Yes No

To The Best Of My Knowledge, I Have Answered The Questions ON This Form Accurately. I Understand That Providing Incorrect Information Can Be Dangerous To My Health. I Understand That It Is My Responsibility To Inform The Doctor And Office Staff Of Any Changes In My Medical Status.

Print Name Of Patient, Parent Or Guardian

If Other Than Patient, Relationship To Patient

Signature

Date

Signature Of Doctor

Date

Patient Name

Date Of Birth

Patient Information Form

Insurance Information

Social History

Family History

Your Medical History

Current Problem