* Required Fields
Last Name *
First Name *
Middle Name
Date of Birth *
Height
Weight
Patient is a child Whom they live with ?
Is the home smoke free?YesNo
Gendermalefemaleother
Marital statussingleMarital
Social Security Number
Address *
City
Zip
StateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Phone (Home)
Phone (Work)
Phone (Cell) *
Email Id *
Race
HispanicYesNo
Language
Reason for visit
Spouse Name (If Married) Or Parent Name (If Child)
Spouse/Parent Date of Birth
Spouse/Parent Social Security Number
Primary MD
Address
Phone Number
Referring MD
Not Known
Sulfa
Penicillin
Codeine
Latex/tape
IV contrast/Iodine
Other
Asthma/COPD
Seizure/Convulsions
Mental illness
Heart problems
High blood pressure
Bleeding tendency
High cholesterol
Diabetes
Stroke/heart attack
Thyroid disorders
Acid reflux/GERD
Radiation to neck
Headaches
Arthritis
Hearing Difficulty
Cancer
None
Tubes
Sinus
Adenoids or Tonsils
Thyroid
Mastoids
Cardiac surgery
Gallbladder
Tracheostomy
Appendix
Heart
Varicose Veins
Breast-Lumpectomy/Mastectomy
Name
Local
Mail Order
Current Medications (Name/Dose, Name/Dose, ...)
Father
Mother
Brother(s)
Sister(s)
Thyroid cancer
Thyroid cancer Father
Thyroid cancer Mother
Thyroid cancer Brother(s)
Thyroid cancer Sister(s)
Head/neck cancer
Head/neck cancer Father
Head/neck cancer Mother
Head/neck cancer Brother(s)
Head/neck cancer Sister(s)
Cancer, Other:
Asthma/Allergies
Asthma/Allergies Father
Asthma/Allergies Mother
Asthma/Allergies Brother(s)
Asthma/Allergies Sister(s)
Hearing loss
Hearing loss Father
Hearing loss Mother
Hearing loss Brother(s)
Hearing loss Sister(s)
Diabetes Father
Diabetes Mother
Diabetes Brother(s)
Diabetes Sister(s)
Heart Disease
Heart Disease Father
Heart Disease Mother
Heart Disease Brother(s)
Heart Disease Sister(s)
Bleeding Disorders
Bleeding Disorders Father
Bleeding Disorders Mother
Bleeding Disorders Brother(s)
Bleeding Disorders Sister(s)
High Blood Pressure
High Blood Pressure Father
High Blood Pressure Mother
High Blood Pressure Brother(s)
High Blood Pressure Sister(s)
Stroke, Other:
Smoking--choose--NeverCigarettesChewing tobaccoPipe/cigarQuit
Alcohol--choose--NeverRare Use1-3days a week4-7 days a weekDailyQuit
Social History Recreational Drugs--choose--Never UsedHas in the pastCurrently usesHave been treated for abuse
Patient Occupation
Veteran
Good general health lately
Recent weight change
Fever
Fatigue
Itching
Rash
Lesion
Lump
Skin Cancer
Bump
Laceration
Wear glasses
Wear contact lenses
Blurred or double vision
Glaucoma
Ringing in ears
Difficulty Hearing
Hearing test within last 2 yrs
Chronic sinus problems
Nose bleeds
Earaches or drainage
Bleeding gums
Sore throat
Hoarseness
Difficulty swallowing
Frequent ear infections
Loss of taste
Chest pain
Palpitations/Irregular heart beat
Heart Attack
Pacemaker
Asthma/wheezing
Shortness of breath
Breathing difficulty
Sleep apnea/disturbance
Abdominal pain
Diarrhea
Heartburn
Nausea
Loss of appetite
Vomitinge
Kidney stones
Rash/itching
Osteoporosis
Back Pain
Weakness
Seizures
Dizzness
Unsteady Gait
Fainting
Heat/cold intolerance
Depression
Abnormal Sleep
Anxiety
Memory loss/confusion
Easy bruising
Past blood transfusions
Exposure to HIV / AIDS
Is this due to an injury ?chooseWould never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
Workers compensation claim chooseWould never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
Date of Injury
Name of Insurance Company
Who holds insurance for the patient ?chooseSelfSpouseFatherMotherOther
Name of Subscriber
Date of Birth
Employer
Phone
Policy or ID Number
Group Number
Enter their initials
Date Of Birth
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