Name: Birthdate: / / Date: /

Name: Birthdate: / / Date: / /

PATIENT HISTORY

Do you have… Additional for Under age 18:

q  Alcoholism / q  Dizziness/Vertigo / q  Lung Problem / q  Mom-Pregnancy
q  Anemia / q  Emphysema / q  Mental Illness / Complications
q  Angina/Heart Attack / q  Epilepsy or Seizures / q  Stroke / q  Complications at
q  Arthritis / q  Glaucoma / q  Thyroid Problem / Birth
q  Asthma/Hay Fever / q  Headaches / q  Tinnitus/noises in ears / q  Childhood Diseases
q  Birth Defects / q  Hearing Loss / q  Tuberculosis / q  Birth Defects
q  Bladder Disease / q  Heart Failure / q  Venereal Disease
q  Bleeding Disorder / q  High Blood Pressure / q  Other ______
q  Cancer: ______/ q  Kidney Disease / q  Other ______
q  Diabetes / q  Liver Problems / q  Other ______

Drug Allergies? If none, please write NONE ______

Current Medications?

Surgeries and Injuries?

FAMILY HISTORY

Has anyone in your family had...

q  Alcoholism / q  Cancer: ______/ q  Kidney Disease / q  Other ______
q  Anemia / q  Diabetes / q  Liver Problem / q  Other ______
q  Angina/Heart Attack / q  Emphysema / q  Lung Problem / q  Other ______
q  Arthritis / q  Epilepsy or Seizures / q  Mental Illness
q  Asthma/Hay Fever / q  Glaucoma / q  Stroke
q  Birth Defects / q  Headaches / q  Thyroid Problem
q  Bladder Disease / q  Heart Failure / q  Tuberculosis
q  Bleeding Disorder / q  High Blood Pressure / q  Venereal Disease

SOCIAL HISTORY

Do You…

q  Exercise Regularly / q  Use Alcohol / q  Use Tobacco / q  Use Drugs
Type: ______/ Beer/Wine/Liquor / Cigarettes/Cigars/Pipe/ / Marijuana/Heroin/
How often:______/ How Often: / Snuff/Chew Tobacco / Cocaine/LSD/Crack

Signature of person filing out information ______

______

For Office Use Only

Reviewed/Updated ___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__

___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__

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