New Patient Information

In order for us to obtain a complete medical history and treat the medical condition that you are seeking help with; we need this form filled out as completely as possible.

Patient Full Name:

Birth Date

Gender of Patient

Gender

Male
Female
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Address

Home Phone Number

Cell Number

Social Security No.

Email Address

Online medical access

Yes or No

Yes
No
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Primary Care Doctor

Preferred Pharmacy

Reason for Today’s Visit

Authorization of Release of Information

I authorize the following person/people to discuss any necessary appointments, treatments, medications, test results, or anything else related to my medical care and/or appointment scheduling. I authorize the following person/people to bring in my child in for treatment and to discuss any appointments, treatments, medications, test results or anything else related to their medical care and/or appointment scheduling.

Full Name

Relationship to Patient

Phone Number

Who would you like us to contact in the case of an emergency?

Full Name

Relationship to Patient

Phone Number

List All Medications and Supplements You Are Taking (Or provide us with a list of your own)

Allergies to Medications:

Yes or No

Yes
No
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Allergies to Medications: If yes, please list below

Have you or any family member ever had an unusual reaction to anesthesia?

Yes or No

Yes
No
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If yes,Who:

MEDICAL HISTORY

Past Medical History

(Please check appropriate boxes)

Heart Attack
Asthma
Diabetes
Emphysema
Coronary Artery Disease
Thyroid
Cancer
Bleeding Disorder
Kidney Disorder
Stroke
Hepatitis
Glaucoma
Hypertension
Heart Failure
Arthritis
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for Diabetes, (Insulin Yes/No)

(Insulin Yes/No)

Yes
No
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for Thyroid, what type:

for Cancer, what type:

Other:

Past Surgical History (Enter approximate date for procedure that applies)

Ear Tubes:

Septoplasty:

Tonsillectomy

Sinus Surgery:

Hernia:

Heart Bypass:

Cataracts:

Back/Neck:

Appendix:

Gall Bladder:

Other:

Family History (Please write who among your immediate family has the following)

Strokes:

Diabetes:

Heart Disease:

Breast Cancer:

Thyroid disorders:

Allergies:

Asthma:

Hypertension:

Hearing Loss:

Cancer:

Other:

Patient Signature:

Clear

Date Signed: