If you are human, leave this field blank. Tell us about yourself Date Time First Name * Middle Name Last Name * How would you like to be addressed? End Section Date of Birth Month * 01 02 03 04 05 06 07 08 09 10 11 12 Day * 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year * 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Gender * Male Female Race * Caucasian African-American Hispanic Asian Native American Decline to answer Marital Status * Single Married Widowed Separated Divorced Its Complicated Address * Address 2 City * State * Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Tel. Number * **Please only list phone & email addresses that we may contact you at regarding your lab results Email Address Personal Doctor Tel. Number Preferred Pharmacy & Location (If Known): Tel. Number Employment Status * Full Time Part Time N/A or Unemployed Occupation Employer Student Status Full Time Part Time Student ID Emergency Contact Tel. Number Relationship End Section Next Insurance Payment Do you have health insurance for today's visit? Yes No Health Insurance Company * ID # * Group # * Tel. Number * Insurance claims Address (P.O. Box / Street) * Suite City * Zip Code * State * Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Are you the policy holder of the insurance plan? * Yes No Name of Policy Holder * Your Relationship to the policy holder * Social Security Number of policy holder Policy Holder's Birth Date * End Section Next Do you have secondary insurance? Yes No Health Insurance Company for secondary insurance ID # for secondary insurance Group # ID for secondary insurance Tel. Number for secondary insurance Insurance claims Address (P.O. Box / Street) for secondary insurance Suite City Zip Code State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Are you the policy holder of the secondary insurance plan? Yes No Name of Policy Holder Your Relationship to the policy holder Social Security Number of policy holder Policy Holder's Birth Date Next Medical History Primary reason for your visit today? * Is the reason for your visit related to a work related injury or a car accident? * No Yes Please explain Please notify Front Desk Staff if you have been in an auto accident or have a Work Related injury Are you presently under a doctor's care for any medical problem? * No Yes Please explain * Please notify Front Desk Staff if you have been in an auto accident or have a Work Related injury Do you have any chronic medical problems? * No Yes Details? * Are you allergic to any medications? * No Yes Please list * Do you have any seasonal or food allergies (hay fever, pollen, ragweed, grass, nuts, shellfish etc.? * No Yes Please list * Do you have any allergies to any other substances (i.e. latex, etc.)? * No Yes Please list * Do you take any prescription or non-prescription medications at this time for this current illness/problem? * No Yes Please list medications with dosage and frequency * Do you take any prescription or non-prescription medications for other reasons? * No Yes Please list medications with dosage and frequency * Any past surgery or hospitalizations? * No Yes Please list any past surgery or hospitalizations you have had & the date of occurrence: * End Section Do you have a family history of any of the following? Diabetes * No Yes if yes please provide details. * Hypertension * No Yes if yes please provide details. * Heart Disease * No Yes if yes please provide details. * Cancer * No Yes if yes please provide details. * End Section Social History Please approximate the average number of times per week you exercise: * Never 1-2 3-5 6-7 Do you currently smoke? * No Yes if yes please provide details. * Have you smoked in the past? * No Yes if yes please provide details. * Do you currently drink? * No Yes Social Drinker if yes please provide details. * Do you have a history of illicit drug use or dependence? * No Yes if yes please provide details. * End Section Next Review of Symptoms General Fatigue or excessive tiredness Body aches and pains Fevers Night Sweats Difficulty Sleeping Unexplained/unplanned weightloss/gain Respiratory Shortness of breath Chronic cough Asthma or wheezing COPD (chronic bronchitis/emphysema) Tuberculosis Pneumonia Skin Rash Itching Moles Sores that don't heal Change in nails Easy bruising Color change Cardiovascular Hypertension Congestive heart failure Angina or blockage of arteries Heart attack Swelling of ankles Heart murmur Rheumatic fever Leg cramps Varicose veins Eyes Glaucoma Cataract Vision Problems Dry and/or itchy eyes Psychiatric Current excessive stressors Anxiety Depression Feeling like hurting yourself Feel like hurting others ENT (Ear Nose Throat) Earache Ear damage Ringing in ears Hearing loss Nose bleeds Chronic sinus problems Bleeding gums Hoarseness or change in voice Genitourinary Delay initiating stream of urine (males esp.) Frequent urnination Burning with urination Blood in urine Sexually transmitted disease HIV or risk factors for HIV Gastrointestinal Nausea/vomiting Heartburn Difficulty swallowing Hearing loss Abdominal pain Jaundice, liver disease or hepatitis Constipation Diarrhea Blood in stool Hemorrhoids Ulcer Hernia Irritable Bowel Syndrome Musculoskeletal Back problems Frequent urnination Arthritis Fibromyalgia Rheumatoid arthritis Past injury or fracture Circulatory System Restless Legs Leg Swelling Leg Fatigue Legs feel heavy, especially after exercise or at night Leg Cramps Endocrine (hormonal) Excessive thirst or hunger Excessive urination Thyroid problems Diabetes Increased weight unintentionally Losing weight unintentionally Neurologic Dizzy spells Fainting spells Seizures Headache Other Cancer Benign tumor Women only Menstual difficulties Vaginal bleeding between periods Breast lumps, pain or discharge Endometriosis Use of birth control pills I have none of the above Signature End Section
