New Patients

Falsifying or excluding any information about your medical history may result in your dismissal from the practice.

All fields are required except where marked "(optional)".

PATIENT INFORMATION

Gender:  
EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

Do you have medical insurance?  
 
OTHER INFORMATION

  
  
REASON FOR VISIT

MEDICAL HISTORY

  Please check any medical problems you have had in the past:  (click "None" if no problems)
Have you had any surgical procedures?  
 
Have you or anyone in your immediate family ever had a serious reaction to anesthesia?  
 
YOUR CURRENT HEALTH

Are you currently taking any medications, vitamins or herbs?  
 
Do you have any drug allergies?  
 
FAMILY HISTORY

  Please indicate if any blood relative has had any of the following and indicate the relative:
  
  
  
  
  
  
  
  
SOCIAL HISTORY

Do you smoke?  
Have you ever smoked?  
Do you drink alcohol?  
Do you use recreational drugs?  
SYSTEM REVIEW

  Please check conditions that apply to your current health:

General

Eyes

Ears, Nose, Throat, Mouth

Cardiovascular
Endocrine

Respiratory

Gastrointestinal
Genitourinary

Males

Females

Allergic/Immunologic

Hematological/Lymphatic
Musculoskeletal

Integumentary

Neurological