Patient History form #1

Please Print ( use only black ink ) DATE _________________

Last Name_______________________________ First___________________________ SS# __________________

Address________________________________ City _____________________________ State _____ Zip _________

Phone ( ) ___________________Gender: [ ] Male [ ] Female DOB _____/_____/______ Age __________

Insurance Co. ________________________________________________ Policy# ____________________________

Employer & Phone Number_________________________________________________________________________

Spouse’s Name __________________________________________ DOB ____/____/______ SS#_______________

Spouse’s Employer & Phone Number _________________________________________________________________

Referred by:____________________________________________________________________

Occupation:

[ ] Professional / Technical

[ ] Tradesman

[ ] Clerical

[ ] Homemaker

[ ] Production

[ ] Service Retail/Other

Marital Status:
[ ] Married

[ ] Widowed

[ ] Separated

[ ] Divorced

[ ] Never Married

Education Level:

[ ] less than 12 years

[ ] High School

[ ] 1-4 years college

[ ] Beyond 4 years college

[ ] Professional school

[ ] Other ____________________________

Date of last X-rays/ Imaging Studies_______________________

Do you NOW have any of the following conditions (MARK ONLY IF YES)

[ ] Congestive Heart Failure?

[ ] Chronic Lung Disease (including Bronchitis of Emphysema)?

[ ] Blindness of trouble seeing, even when wearing glasses?

[ ] Deafness or trouble hearing?

[ ] Sugar Diabetes (Diabetes Mellitus) Type1?

[ ] Sugar Diabetes (Diabetes Mellitus) Type II adult onset?

[ ] Asthma?

[ ] Ulcer or gastrointestinal bleeding (not counting Hemorrhoids)?

[ ] Arthritis or Rheumatism?

[ ] Sciatica of chronic back problem?

[ ] Hypertension of High Blood Pressure

[ ] Angina?

[ ] Heart Attack of Myocardial Infarction?

[ ] Stroke?

[ ] Kidney disease?

[ ] Cancer?

[ ] Depression?

[ ] Other? ____________________________

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[ ] Do you smoke? If you smoke cigarettes, how many to you smoke in an average day?

[ ] Less then ½ pack [ ] ½ to 1 pack [ ] 1 to 2 packs [ ] More than 2 packs

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[ ] Do you drink? If you drink alcohol, about how many drinks in an average day?

[ ] 1 [ ] no more than 1 [ ] 1 or 2 drinks [ ] 3 to 5 drinks [ ] 6 to 8 drinks

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1. List all medications including over counter products)

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2. List all operations / surgeries you have had:

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