Patient Information Form

Patient Name

DOB

Social Security Number

Height

Weight

Address

City

State

Zip Code

Phone Number

Alt. Phone Number

Email Address

Emergency Contact

Relationship

Telephone

Allergies (Medicine/Food)

I have no allergies to medicine or food

Medication

Dose

How Often

Add Additional Medications

Personal Medical History

Please list any Other conditions/diseases

Family Medical History

Please state the family member, condition/disease, and age of death if no longer alive:

Additional Family Medical History Entry

Social History

Occupation

Martial Status

Single Married Divorced Widow/Widower

How Often Do You Exercise?

(Days per week/intensity/etc.)

Special Diet

Tobacco Use:

Yes No

Packs per day?

How many years?

Past Use:

Yes No

If so, when did you quit?

Alcohol Use:

Yes No

How Often?

Daily Once or twice per week Once or twice per month Once or twice per year

Amount per episode:

Type:

Street Drugs:

Yes No

How Often:

Amount:

Type:

Surgical History

Please list any surgical procedures you have had. These include tonsillectomy, wisdom teeth, cardiac procedures and joint replacements, to name a few.

Additional Surgeries

Preferred Pharmacy and Location

My signature below acknowledges that I was offered the opportunity to view the office’s privacy policy regarding my medical records (HIPAA) and that I authorize evaluation and treatment by the physician. I also authorize the office to submit claims directly to my insurance company. I also acknowledge that I am responsible for all deductibles and/or copays as per my insurance guidelines.

***Please note that you cannot be seen by the physician until this form is signed as it is consent for treatment.***

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Your information will be encrypted.