Today Date
    First Name
    Last Name
    MI:
    I Prefer to be called:
    Birth Date
    S&H:
    Home Address:
    City:
    State:
    ZIP:
    Single
    Married
    Divorced
    Widowed
    Separated
    Home Phone
    Cell #
    Work#
    Email:

    PRIMARY INSURANCE

    Insurance Co:
    Insured's Name:
    Insured's DOB:
    ID #
    Group

    Have you ever had any of the following diseases or medical problems?

    Abnormal Bleeding
    Glaucoma
    Mitral Valve Prolapse
    Alcohol/Drug Abuse
    Hay fever
    Osteoporosis/Paget’s
    Anemia
    Heart Attack
    Pacemaker
    Arthritis
    Heart Murmur
    Psychiatric Care
    Artificial Bones/Joints/Valves
    Heart Surgery
    Radiation Treatment
    Asthma
    Hemophilia
    Rheumatic/Scarlet Fever
    Blood Transfusion
    Hepatitis
    Seizures
    Cancer/ Chemotherapy
    Herpes/Fever Blisters
    Shingles
    Colitis
    High Blood Pressure
    Sickle Cell Disease/Traits
    Congenital Heart Defect
    HIV/AIDS
    Sinus Problems
    Diabetes
    Hospitalize for any reason
    Stroke
    Difficulty Breathing
    Kidney Problems
    Thyroid Problems
    Emphysema
    Liver Disease
    Tuberculosis
    Fainting Spells
    Low Blood Pressure
    Ulcers
    Frequent Headaches
    Lupus
    Veneral Disease

    Are you Allergic to any of the followings:

    Aspirin
    Erythromycin
    Tetracycline
    Codeine
    Latex
    Other
    Dental Anesthetics
    Penicillin
    Please lit any other drugs/ materials that you are allergic to:
    Are you pregnant?
    Yes No
    Do you smoke or use tobacco in any other form?
    YesNo
    Have you had any metal rods, pins implants?
    YesNo
    Are you taking any prescription/ aver-the-counter or herbal supplemental drugs?
    YesNo
    Please list each one:
    Signature
    Reviewed by clinical staff: