Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Name* First Last Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Are you allergic to any medications, foods, latex or dyes?*Do you smoke?*YesNoAre you a former smoker?*YesNoHow much do you smoke?Do you drink alcohol?*YesNoAre you a former alcoholic beverage drinker?*YesNoDo you use illegal drugs? (marijuana, cocaine, meth, etc.)*Patient Health HistoryPlease indicate which conditions apply to you OR your family (please indicate which family member - Mother, Father, Sibling, Grandparent)Cancer You Family Member Kind of CancerIndicate Family Member and Kind of CancerHigh Blood Pressure You Family Member Indicate Family MemberHigh Cholesterol You Family Member Indicate Family MemberHeart Attack You Family Member Indicate Family MemberStroke You Family Member Indicate Family MemberHeart Problems You Family Member What Kind?Indicate Family Member & Kind of Heart ProblemsDiabetes You Family Member Indicate Family MemberThyroid Problems You Family Member What Kind?Indicate Family Member & Kind of Thyroid ProblemsLung Problems You Family Member What Kind?Indicate Family Member & Kind of Lung ProblemsKidney Disease You Family Member What Kind?Indicate Family Member & Kind of Kidney DiseaseSurgeries or Hospitalizations You Family Member What Kind?Indicate Family Member & Kind of Surgeries or HospitalizationsAnxiety/Depression You Family Member Indicate Family MemberAre You Pregnant? Yes Last Menstral Period?Other You Family Member Describe Other ConditionIndicate Family Member & Describe Other ConditionMedicationsPlease list all medications you are taking including prescribed, herbal, vitamins, and over the counter meds. Click the green + to add another medication.Start DateMedicationDoseFrequency Preferred PharmacyCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
