Date: _____________

PERSONAL:

Last Name: ___________________   First Name and M.I. _________________________

Permanent  Address: _____________________________
Mailing Address if different:________________________ 
City, State, Zip: ___________________________________
Telephone: _______________________ email: ___________________________

Date and Place of Birth: _________________________            Marital Status: _____
Sex: ____________    Name of Spouse: _________________________
Present or former occupation _______________________________
Date of last physical examination ____________  Physician  _______________________

Responsible Party:  Self ___   Parent _____ Other _______    If other fill in next table.

Emergency Contact Name: ___________________ Telephone: _____________

MEDICAL HISTORY

Present Medications/Dosage/Frequency/Physician/Taking Since

1__________________________________________________________

2__________________________________________________________

3__________________________________________________________

4__________________________________________________________

5__________________________________________________________

Over the counter medicine taken regularly-Name/Dosage/Frequency Taken

1__________________________________________________________

2__________________________________________________________

3__________________________________________________________

4__________________________________________________________

5__________________________________________________________

Drug Allergies-Describe:

__________________________________________________________________________________

Physical:

Height _____ Weight Today_____ Weight One Year Ago _____  Height  _________
Do you smoke:________   When did you stop:_______ How many packs/day ______
Do you drink alcohol: None ____ Occasionally_____ More than occasionally _____ 
Have you had any alcohol or drug dependency problems __________

Operations/Condition/Date

1______________________________________________________________

2______________________________________________________________

3______________________________________________________________

Disease History  Yes(Y), No(N), or Don't Know(?)

Measles ___  German Measles ___  Mumps  ___  Chicken Pox  ___ Arthritis or Rheumatism ____            Any bone or joint disease  ___  Gallbladder Disease  ___  Epilepsy/Seizure/Convulsion  ___
Diabetes ____ Cancer___  Depression/Nervous Breakdown/Emotional Problems ___  Hay Fever or Asthma  ___  AIDS  _____  Rheumatic Fever ____  Tuberculosis ____  Thyroid Problems _____ 
Hepatitis/Liver Problems ____  Heart Disease ______ 

Conditions History  Do you have now or have you had within the past year?  (Y, N, or ?)

Frequent or Severe Headaches ____  Dizziness on change of position ____ Blurred Vision ____  Any other Vision Problems _____ Earaches____  Decrease in Hearing ____  Recurrent nose bleeds  ____ Chest Pain _____   Heart Attack____  Irregular Heart Beat/Pacemaker _____Abnormal Bleeding tendency  ____  Asthma, Emphysema, Bronchitis ____ Chronic or Frequent Cough_____Shortness of Breath _____
High Blood Pressure ____ Belching or heartburn ___ ( Relieved by food or medication ____) Stomach or colon disorders _______ Nausea/vomiting/Diarrhea _____Vomited Blood ____  Abdominal Cramping____Change in size, shape, or texture of bowel movement ________ Blood in bowel movement Recurrent Back Pain ______   Backaches  ______   Tiredness or weight loss without apparent reason _______  Cancer ___ Any other medical problems not listed above ________________________________________________________

X- Ray History of Urinary Tract (when last one taken). Indicate if C/T scan or ultrasounds were performed.
___________________________________________________________________________________

Menstrual History (Women only)

Frequency  Regular (Y, N, or varies) ________  Flow (heavy, medium, light) ________   Date of last period________   Date of last pelvic exam ______ Any discharge from vagina (Y/N) _______________

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