PATIENT INFORMATION First Name MI Last Name Preferred Name Date of Birth Age Sex Height Weight Mailing Address City State Zip Home Phone Work Phone Cell Employer Occupation SS# Drivers License # Email Marital Status: MarriedDivorcedSingleWidowedSeparated If Married: Name of Spouse Date of Birth SS# Employer Occupation Work Phone How were you referred to our office? COMPLETE BELOW IF PATIENT IS A MINOR Father’s Name SS# Date of Birth Employer Work phone Cell Phone Mother’s Name SS# Date of Birth Employer Work phone Cell Phone INSURANCE INFORMATION Primary Insurance Carrier Phone Number Insured Name SS# Employer Date of Birth Secondary Insurance Carrier Phone Number Insured Name SS# Employer Date of Birth MEDICAL HISTORY Do you have any of the following medical conditions? Check ONLY those that apply. Heart Condition/murmurPins,plates, screwsNervous problemsRecent Weight LossArtificial valve/jointRespiratory disease/AsthmaPsychiatric problemsAIDS/HIV positiveRheumatic/Scarlet feverShortness of breathSleep ApneaHepatitisMitral Valve ProlapsePanic attacksChemical dependencyKidney/liver diseaseCongenital heart diseaseSinus ProblemsAnemia/HemophiliaYellow JaundiceHigh blood pressureThyroid problemsBlood diseaseVenereal diseaseChest pain/strokesUlcer/stomach issuesBlood TransfusionEpilepsy/seizersDizzy spells, faintingDepressionBleeding ProblemsDiabetes Are you allergic to any of the following: Check ONLY those that apply. LatexPenicillinLocal AnestheticSulfaCodeineAspirinOthers Do you have any condition or disease not listed above? Are you under the care of a physician? Dr. Name Which is bigger, 11 or 4? Please leave this field empty.