New Patient Form

HEALTH HISTORY

Past Surgical History and Hospitalizations*

Please list all procedures (with dates and reasons)*

Are you or have you ever been a smoker?*

Do you live with a smoker?*

Do you drink alcohol?*

Number of drinks per week?*

Do you drink Caffeine?*

Do you take recreational drugs?*

Currently Employeed?*

Do you have children?*

Number of children?*

Are you Pregnant?*

Medical History*

Please CHECK any current or past conditions

What is your current A1C?*

Family History*

Please CHECK if any family member current or past conditions (Pick condition and then complete family member, pick another condition and then complete family member, etc.)

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

List Who*

Mother
Father
Sibling
Child
Grandmother
Grandfather

Please list all allergies/sensitivities*

Please list all current medications*

Step 1 of 5

PATIENT INFO

PATIENT CONTACT

EMPLOYMENT

PRIMARY PHYSICIAN

GUARANTOR INFO

INSURANCE INFO

HEALTH HISTORY

REVIEW OF SYMPTOMS

OFFICE POLICY AND SIGN OFF