Step 1 of 3 - Patient’s Medical History 33% Physician InformationPhysician’s Full Name* City, State, Zip Code* Are you currently under a Physician’s Care?*Select OneYesNoIf yes, for what? Have you been hospitalized in the last two years?Select OneYesNoIf yes, for what? Are you taking any medications, drugs, or pills?Select OneYesNoIf so, Please list the names and dosages of each Do you smoke?Select OneYesNoIf yes, how much? Women OnlyAre you pregnant?Select OneYesNoAre you taking birth control pills?Select OneYesNoAre you nursing?Select OneYesNoAre you on hormone therapy?Select OneYesNoPatient’s Current or Previous ConditionsSelect any of the following if you presently have or have had the condition in the past:* Allergic to Penicillin Allergic to Codeine Pre-Medication required Pacemaker Allergic to Tetracycline Allergic to Novocain Mitral Valve Prolapse HIV Positive Allergic to Aspirin Allergic to Latex Rubber Heart Problems Prior Hepatitis Other If other, please note Medical ConditionsPlease select all that applies* Acid Reflux Anemia Arthritis/Gout Artificial Heart Valve Artificial Joint Replacement Asthma Blood Disease Blood Transfusion Cancer Chemical Dependency Chemotherapy Chest Pain Cold Sores/Fever Blisters Congenital Heart Problem Cortisone Treatment Deep Vein Clot Diabetes Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Extreme Nervousness Fainting or Dizziness Frequent Cough Gastrointestinal Upset Glaucoma Hay Fever Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis A or B Herpes High/Low Blood Pressure Hives Hypoglycemia Kidney Disease Liver Disease Lung Disease None Osteoporosis Parathyroid Disease Psychiatric Care Rheumatic Fever Rheumatism Scarlet Fever Shortness of Breath Sickle Cell Disease Sinus Trouble Stroke Swelling of Feet/Ankles Thyroid Disease Tuberculosis Ulcers Venereal Disease X-Ray or Cobalt Treatment Yellow Jaundice I hereby certify that the foregoing information is accurate and complete and that I will notify the office of any changes in a timely manner. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I may have made in completion of this form. ** PLEASE BE ADVISED ALL PAYMENTS ARE NON-REFUNDABLE & WE ONLY ACCEPT CASH AND CREDIT, NO CHECKS**Date* SignatureWitness* CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
