Patient Information Form

Date

First Name

Last Name

Date Of Birth

Age

Sex

Male

Female

Home Address

City/State

Zip

Home Phone

May We Leave a Message?

Yes

Alternate Phone

May We Leave a Message?

Yes

May We Leave a Message?

Yes

Primary Language

Do you have a legal guardian or HealthCare Power Of Attorney?

Yes

If yes, Name

Relationship

Phone

Emergency Contact

Relationship

Phone No

Primary Care Doctor

Who Referred You to Us?

Pharmacy

Location

Phone No

Is There A Family Member Or Other Person You Would Like For Us To Share Your Medical Information?

Yes

Who Is Responsible For Payment?

Relationship to Patient?

Address

City/State

Zip

Phone

Insurance Information

Primary Insurance Company Name

Address

City/State

Zip

Phone

Insured Name

Date / Time

Phone

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

Type of Exercise

Family History

Patient Name

Date of Birth

Your Medical History

Condition	Yes	No	Condition	Yes	No	Condition	Yes	No
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	THYROID DISEASE	Y	N
DIABETES	Y	N	MITRAL VALVE PROLAPSE	Y	N	TUBERCULOSIS	Y	N

Current Problem

What Specific Problem Brings You To Our Office Today?

Where Is The Pain/Problem Located? Please Mark On The Pictures Below.

How Long Ago Did This Problem Start?

day

week

month

year

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 Blow Box)

If Yes, Was It A Work- Related Injury?

Yes

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

Signature Of Doctor

If Other Than Patient, Relationship To Patient

Date

Signature

Date

Patient Name

Date Of Birth

Opening Times