Medical Information Form

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

Office Hours

Our Regular Schedule

Monday:

8:00 am-5:00 pm

Tuesday:

8:00 am-5:00 pm

Wednesday:

8:00 am-4:30 pm

Thursday:

8:00 am-5:00 pm

Friday:

8:00 am-4:30 pm

Saturday:

Closed

Sunday:

Closed

Location

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