Patient Information

First name

Last name

Patient’s date of birth

Gender

Street address

City

State

Zip

Phone number

Emergency Contact Information

Emergency contact name

Emergency contact’s relationship to you

Emergency contact’s phone number

Insurance Information

Insurance Provider

Insurance Policy Number

Policy Subscriber Name

Subscriber’s date of birth

Subscriber’s Social Security Number

If you are under the care of other medical providers, please give their contact information

Health History

Do you have allergies

If yes, please specify here

Do you take any medications or supplements that are prescription or over-the-counter?

List any current medications you are taking (prescription and over-the-counter)

Have you ever been diagnosed with or received treatment for any of the following conditions: High blood pressure, Diabetes, Asthma, Heart disease, Stroke, Cancer, Thyroid disorders, Kidney disease, Liver disease, Arthritis, Depression, Anxiety, Other?

If yes, please provide details on any medical condition(s) you checked above, including the dates of diagnosis and any current treatment.

Are there any significant medical conditions that run in your immediate family (parents, siblings)?

If yes, please specify

Do you smoke?

If yes, how many cigarettes do you smoke each day?

Do you consume alcohol?

If yes, how frequently and in what quantities?

How did you hear about us?

Is there anything else you would like us to know or any specific concerns you have?

Do you confirm that the information provided in this form is accurate and complete to the best of your knowledge?