PATIENT INFORMATION

We are pleased to welcome you to our practice. Please take a few moments to completely fill out this form as

accurately as possible. All fields are mandatory. If you have questions, we will be happy to help you.

Last Name (Legal) *

First & Middle Name (Legal) *

Preferred Name *

Address *

City *

State *

Postal code *

Phone *

Email *

Date of birth

Gender

Male

Female

Gender ID *

Male

Female

Transgender

Employer *

Social Security Number *

Occupation *

Marital Status *

Married

Single

Other

Reason for coming in *

Primary Care Doctor: (Name and Phone Number) *

Pharmacy: (Name, Address or Phone Number) *

Whom may we thank for referring you?

Name of Referral, Hospital, or Physician (if applicable)

Emergency Contact

Emergency Contact: (who can we discuss medical care with) *

Relationship to Patient: *

Emergency Contact Phone Number *

Health Questionnaire

Weight *

Recent Weight Loss: *

Height *

Family History _________ Relationship

Family History & Relationship *

Bleeding Disorder
Breast Cancer
Cancer
DVT/Pulmonary Embolism
Heart Disease
High Blood Pressure
Diabetes

Social History

Use of Alcohol? *

Never

Daily

Occasionally

Do you use drugs? *

Yes

No

Somtimes

Drugs: How often and what kind?

Tobacco/Nicotine Use? *

Never

Not Now

Yes Currently

How many packs per week? How many Years?

Tabacco/Nicotine Quit Date (If applicable)

List all hospitalizations, operations, and serious injuries *

List ALL medications current taking *

Nausea/Vomiting with pain meds? *

Allergies & Effects

Allergies & Effects *

Penecillin
Latex
Antibiotics
Iodine
Other

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Current/History of Illness and Medical Problems *

Anemia

Anesthesia Complications

Anxiety

Arthritis

Asthma

Autoimmune Disorder

Bleeding Disorder

Bleed/Bruises Easily

Bowel Problems

Breast Disease

Cancer

Constipation

Depression

Diabetes

Dry Eyes

DVT

Emphysema

Fluid Retention

Headaches

Heart Attack

Heart Disease

Heart Murmur

Hepatitis

Herpes Cold Sores

High Blood Pressure

HIV/AIDS

Mastitis

Pneumonia/Bronchitis

Prediabetes/Insulin Resist

Rheumatologic Disorder

Seizures

Stroke

Thyroid Problems

Ulcer

Do you take any of the following? *

Aspirin/Excedrin

Ibuprofen/Advil/Motrin

Vitamine E/Multi Vit

Herbal Remedies

Tylenol/Acetaminophen

Green Tea

Omegas/Flax seed

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History of poor or bad scarring?

See a pain management specialist?

Do you have a history of staph?

Had any infection post op surgery?

Women Only

Breast biopsies?

Last mammogram date

Mammogram results

History of breast cancer

Number of children

I acknowledge that I answered all questions on the patient registration form truthfully and honestly. I am aware that this is my responsibility to inform the physician or nurse of my current medical or health conditions and to update this history as a current medical history.

Signature *