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Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Patient History

If not listed here: Please Discuss with your Physician

Social History

 

Tobacco Use

 
What is your smoking status?
Do you use other tobacco products?
Does anyone in your household smoke?
At what age did you begin smoking?
At what age did you quit?
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoke per day?

Alcohol Use

 
Do you consume alcohol?
How much?
 
Number of drinks:
Per:

Other

 
IV drug use or other recreational drug use?
How often do you exercise (times per week)?

If not listed here: Please Discuss with your Physician

Surgical History

 

Please mark all surgeries you have had:

 
Have you ever had a Blood Transfusion?
Cesarean Section
Heart Valve Replacement

If not listed here: Please Discuss with your Physician

Allergies

 

Please list all items you are allergic to:

 

If not listed here: Please Discuss with your Physician

Medications

 

If not listed here: Please Discuss with your Physician

Your Medical History

 

Please indicate if you have a history of the following:

 
Alcohol abuse
High blood pressure
Allergies / Sinus
High cholesterol
Alzheimer's disease
HIV / AIDS
Anemia
Hypothyroid (low thyroid)
Anxiety
Irritable Bowel Syndrome (IBS)
Arthritis
Kidney stones
Asthma
Liver cancer
Bipolar disorder
Lung cancer
Birth defects
Lupus
Bleeding disease
Migraines
Blood clots
Multiple Sclerosis (MS)
Breast cancer
Osteoporosis
Cataracts
Parkinson's disease
Colon cancer
Prostate cancer
Congestive heart failure
Prostate problems
COPD / Emphysema
Reflux / GERD
Coronary artery disease
Rheumatic fever
Crohn's disease
Rheumatoid Arthritis
Depression
Seizures / Convulsions
Diabetes type 1
Sexually Transmitted Disease (STD)
Diabetes type 2 (adult onset)
Sleep Apnea
Gout
Stomach ulcer
Heart disease
Stroke / CVA of the brain
Hepatitis B
Suicide attempt
Hepatitis C
Tuberculosis (TB)

If not listed here: Please Discuss with your Physician

Family Medical History

 

Please indicate which family members have had these illnesses:

 
Alcohol abuse
Anxiety
Arthritis
Asthma
Blood disorder
Breast cancer
Colon cancer
Other type of cancer
COPD
Dementia
Depression
Depression
Gastrointestinal disorder
Heart disease
High blood pressure
High cholesterol
Kidney disease
Obesity
Skin cancer
Skin cancer
Thyroid disorder

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This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.