All information is strictly confidential.
Reason for Visit
For InjuriesDate of Injury
On the job?
What is the most you have ever weighed
Past Medical HistoryPlease check if you have, or ever had any of the following conditions:
Are you being treated for any other illness at this time?
If yes, please explain:
Date of Last Physical
Have you ever had Surgery?
If yes, please list
Have you, or a family member ever had a problem with anesthesia?
If yes, please explain
Have you been diagnosed with a sleep disorder/sleep apnea?
Do you use a C-Pap Machine for your sleep disorder?
Do you have any Drug Allergies?
If yes, please note name of drug and reaction:
Family HistoryOnly list blood-related relatives.
High Blood Pressure
List all medications you are taking with name and dosage
Accutane (past year)
Are you taking or have you ever taken recreational drugs?
Please give more details
Do you smoke?
How much per day?
Do you drink?
Additional Health History (Female Gender or FtM, please complete)
Date of Last Menstrual Period
Are you pregnant?
Date of Last Mammogram
History of Breast Biopsy
Current Bra Size (Female Gender Only)
Review of SystemsSelect the following symptoms you have had recently.
Eyes, Ears, Nose & Throat
To the best of my knowledge, the above information is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian, or Personal Representatives
Name of Patient, Parent, Guardian or Personal Representative
One fine body…