Date
Full Name
*
Email
*
Phone
*
Marital Status
Single
Married
Partnered
Seperated
Divorced
Widowed
Sex
Male
Female
Height
Weight
PCP or Referring Physician
Date Of Last Medical Exam
Reason For Visit
How Did You Hear About Us?
-If applicable, please indicate the affected area(s) on the body:
Please list other medical problems that doctors have diagnosed
My Goal is to:
PAST MEDICAL HISTORY
Nose
Congestion
Frequent Colds
Nosebleeds
Polyps
Post Nasal Drip
Seasonal Allergies
None
Head
Hair loss
Head injury
Headache/Migraine
Dandruff
Oily/Dry hair
None
Other
Cardiovascular
Abnormal EKG
Angina/Chest Pain
Aortic Stenosis
Arrhythmia
Atrial Fibrillation
Circulation Problems
Edema/Feet Swelling
Heart Attack
Heart Failure
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Murmur
Pacemaker/De brillator
Palpitations
Rheumatic Fever
Shortness of Breath
None
Neck
Enlarged Thyroid
Stiffness
Swollen Glands
Tension
None
Eyes
Blurry Vision
Corrective Lenses
Cataracts
Dark Under Eyelid
Discharge
Double Vision
Dry
Glaucoma
Itchy
Macular Degeneration
Strain
Last Eye Exam:
None
Lungs
Abnormal Chest X-ray
Asthma
Bronchitis
Cough/Cold
Emphysema
Pneumonia
Shortness of Breath, with:
Exertion Sitting Lying
Sleep Apnea
TB - positive skin/sputum
Wheezing
None
Genital / Urinary
Blood/Discharge in Urine
Dialysis - Days of the week:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Frequent Urinary Tract Infections
Kidney Stones
Kidney, Renal, or Urinary disease
Loss of urine, with:
Cough/sneeze
Incontinence
Painful Urination
Prostate Problems
Sexual Problems
Urinary Catheter
None
Mouth / Throat
Amalgam/Silver Filings
Canker/Cold Sores
Carries/Cavities
Dentures
Gum Disease
Hoarseness
Loss of Taste
Sore Throat
Last Dental Exam:
None
Gastrointestinal
Bloating
Bloody/Black bowel movements
Change in Appetite
Constipation/Diarrhea
Gall Bladder Problems
Hemorrhoid(s)
Heart Burn/Indigestion
Hiatal Hernia
Jaundice
Liver Disease
Nausea/Vomiting
Recent Weight Loss
Rectal Bleeding
Pancreatitis
Ulcer(s)
None
Hematological
AIDS/HIV
Anemia
Bleed Easily
Blood Clotting Problems
Bruising
Hepatitis
High Cholesterol
Sickle Cell Disease
Transfusion (Plasma)
None
Nervous system
Autism
Carpal Tunnel
Convulsions
Dementia
Dizziness
Fainting
Spells/Blackouts
Falls
Forgetfulness
Memory Loss
Multiple Sclerosis
Numbness/Weakness
Seizures/Epilepsy
Stroke
Tingling
Tremors
Weakness
None
Endocrine
Adrenal fatigue
Diabetes
Low Blood Sugar
Sweats/Chills
Thyroid Problems
None
Other:
Mental / Emotional
Anger/Irritability
Anxiety
Depression
Eating Disorder
Fear
High-Strung/Tense
Panic Attacks
Psych Hospitalization
Suicidal
None
Musculoskeletal
Arthritis
Arm/Hand Weakness
Chronic Back/Neck Pain
Leg
Cramps
Leg Weakness
Muscular Dystrophy
Muscle/Joint Pain
Pain
None
Skin
Color change
Dry
Hives
Itchy
Lump
Perspiration
Psoriasis/Eczema
Rash
Warts/Moles
None
Other
Autoimmune Disease
Cancer
Infection(s)
Sleeping Problems
Hearing Loss
Right Ear
Left Ear
CT:
MRI:
Ultrasound:
X-ray:
Other
IMMUNIZATIONS/VACCINATIONS
Chickenpox
Pertusis - Whooping Cough (DTaP, Tdap)
Pneumococcal (PCV)
Diphtheria (DTaP, Tdap)
Haemophilus (Hib)
Polio (IPV)
Hepatitis A (HepA)
Rotovirus (RV)
Hepatitis B (HepB
Rubella - German Measles (MMR)
Flu
Tetanus (DTaP, Tdap):
Measles (MMR)
Mumps (MMR)
SURGERY
Year of Surgery
Type of Surgery
Surgery Hospital
OTHER HOSPITALIZATIONS
Year of Hospitalization
Reason for Hospitalization
Hospital
ALLERGY
Allergy
Type of Reaction
MEDICINE / OTC MEDICINE / VITAMINS / HERB / HOMEOPATHICS / ETC
Medicine
Strength
Times/day
Reason
Prescriber
I do not take medicine.
PATIENT INFORMATION
Patient Name
Patient Date of Birth
Patient Address
Patient Phone Number
Patient Email
Preferred form of communication
Preferred form of communication
Phone
Email
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EMERGENCY CONTACT
Emergency Contact Person Name
Emergency Contact's Phone
Emergency Contact's Address
Relationship to Patient
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