New Patients

Health History

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

First Name

Last Name

Home Phone

Business/Cell Phone

Address

City

State

Zip

Occupation

Height

Weight

Date of Birth

Sex

SS# or Patient ID

Emergency Contact

Relationship

Home Phone

Cell Phone

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the question)

Medical Information

Please indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the question)

Physician Name

Phone

Address

City

State

Zip

Has there been any change in your general health within the past year?

Yes

What condition is being treated?

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

What was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes

Date of last physical exam

Please list all, including vitamins, natural or herbal preparations and/or dietary supplements

Allergies. Are you allergic to or have you had a reaction to:

Please indicate if you have or have not had any of the following diseases or problems:

Has a physician recommended that you take antibiotics prior to any treatment?

Yes

Name of physician

Phone

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes

Please explain

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that the doctor and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the Doctor, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.