Patient´s Name (Last, First):  Name Prefer to be called:  

The best time to contact me is:  A.M. P.M on  my Home Work Cell Phone

Date of Birth:   Social Security Number:

Check Appropiate Box: Minor  Single Married  Widowed  Separated  Divorced

Spouse or Parent´s Name:   Phone:

Employer:  Work Phone:   

Whom may we thank for referring you?:  

Person to contact in case of emergency:  Phone:

Email Address:  

Physician's name:   Phone:

Pharmacy's name:  Phone:  

Name:  Relationship to Patient: 

Address:  City:  

Employer:

State:  Zip:  Ins. Co. Phone:

High blood pressure:

Yes No

Epilepsy:

Yes No

Low blood pressure:

Yes No

Hepatitis:

Yes No If yes, Type:

Abnormal bleeding:

Yes No

Kidney Problems

Yes No

Mitral Valve Prolapse:

Yes No

Liver Disease

Yes No

Angina Pectoris:

Yes No

Colitis

Yes No

Artificial Heart Valve:

Yes No

Diabetes

Yes No

Congenital Heart Defect:

Yes No

Psychiatric Problems

Yes No

Heart Surgery:

Yes No

Seizures

Yes No

Stroke:

Yes No

Drug Abuse

Yes No

Heart Attack:

Yes No

HIV + AIDS

Yes No

Pace Maker:

Yes No

Allergies , If yes to:

Yes No

Anemia:

Yes No

Other Medical Conditions:

Hemophilia:

Yes No

If Female:

Taking Birth Control Pills

Yes No

Glaucoma:

Yes No

Pregnant, If Yes # of weeks

Yes No   Weeks:

Asthma:

Yes No

Nursing

Yes No

Emphysema:

Yes No

Difficult Breathing:

Yes No

Tuberculosis:

Yes No

Pneunocystitis:

Yes No

Arthritis:

Yes No

Cancer-Chemotherapy:

Yes No

Radiation Therapy:

Yes No

Thyroid Problems:

Yes No