Patient Name:_________________________________ D.O.B.:_____________________________
Patient Medical Information:
**THIS INFORMATION IS IMPORTANT FOR OUR RECORDS FOR TREATMENT AND YOU HEALTH**
Age:___________ Height:____________ Weight:______________ Shoe Size:___________________
Primary Care Physician:___________________________ Phone Number:_______________________
What Is The Reason For Your Visit Today?________________________________________________
PLEASE MARK ANY OF WHICH APPLY TO YOU:
__ Diabetes __ Seizure Disorders __ Arthritis
__ Heart Trouble __ Bleeding Disorders __ Asthma
__ Circulatory Problems __ Hypertension(High BP) __ Epilepsy
__ Kidney Trouble __ Hypotension (Low BP) __ Hepatitis
__ Rheumatic Fever __ Nervous Condition __ Stroke
__ Stomach Ulcers __ Sickle Cell Anemia __ Heart Attack
__ Skin Problems __ Liver Disease __ Cholesterol Problems
__ Tuberculosis __ Epilepsy / Seizures __ Anemia
__Glaucoma __ Back Problems __ Eating Disorders
__Joint Replacements __ Scarlet Fever __ Pacemaker
__Chest Pain __ Swelling of Feet __ Blood Disease
__Other:___________________________________________________________________________
ALLERGIES:(MARK WHAT APPLIES TO YOU)
__ Foods __ Sulphites __ Iodine
__ Aspirin __ Sulphur __ Tape
__ Codeine __ Local Anesthesia __ Penicillin
__ Novocaine __ Dyes
__Other:___________________________________________________________________________
Past Surgical History:_________________________________________________________________
___________________________________________________________________________________
Present Medications:__________________________________________________________________
___________________________________________________________________________________
Family History: Diabetes, Circulatory, Hypertension, Bleeding Disorders, Arthritis, Problems with Anesthesia, Other:____________________________________________________________________
Social History:
Tobacco Use: Y/N (Pks/Day)________ Coffee: (Cups)_______ Alcohol:___________
Do You Take Aspirin Daily? Y/N Do You Faint Easily: Y/N