First Name

Last Name

Address

City

State

Zip Code

Date of Birth

SSN

Phone Number

2nd Phone Number

Driver’s License #

State Issued

Email Address

General Health Information                   Circle Yes or No
For any YES answers, please record the item number and list details. Include any surgeries, physicians seen, dates, durations. Please Include any physician’s seen phone number and address.

1.       Do you have any allergies?

Yes

No

Comment Section:

2.        What Medications are you currently taking (include dosage & frequency) Please answer in comment section.

3.       Do you smoke?

Yes

No

4.       Have you had any surgeries? (Please list dates & procedure)

Yes

No

5.       What medications are you requesting?

List in comments

6.       Have you taken this medication before?

Yes

No

7.       If yes, when did you take it & was it effective?

Yes

No

8.       Have you taken other medications for this condition, if so please list.

Yes

No

9. What is your chief Medical complaint, please answer in comments section.

10. Do you have history of:

a. Anxiety, Depression, or other mental problems?

Yes

No

b. Kidney Stones

Yes

No

c. Arthritis, Fibromyalgia, or Joint Pain

Yes

No

d. Nausea

Yes

No

e. Stomach ulcers, Intestine, or other digestive problem?

Yes

No

f. Blood disorders?

Yes

No

g. Neurological disorders?

Yes

No

h. Cancer?

Yes

No

i. Respiratory disorder?

Yes

No

j. Glaucoma or eye problems?

Yes

No

k. Sleeping problems?

Yes

No

l. Heart problems including angina, blood pressure, heart disease, failure, or heart attack?

Yes

No

m. HIV/AIDS?

Yes

No

n. Stroke

Yes

No

o. Thyroid, diabetes, or endocrine disorder?

Yes

No

11. Where is the Pain, circle one or more:

12. Please mark where pain is located.

Neck           Shoulders        Head          Legs

Arms          Lower back      Upper Back

Joints    Herniated Disc    Other

13. Describe the Pain:

Sharp   Shooting    Dull    Localized    Electric

Diffuse    Burning    Throbbing    Steady

Intermittent    Cramping    Deep   
Stabbing

Height (in shoes)

Weight

Chest (full inspiration, male only)

Chest (forced expiration, male only)

Adbomen (at umbilieus, male only)

15. Blood Pressure ( Right arm while seated. Take 2 readings and record, do not disregard any.) If systolic is over 140 or diatolic over 90 take 3^rd and 4^th reading after 10 min. est.

1st

2nd

16. Pulse Rate (at rest). Record for 1 full minute

Irregularities/min

17. Did you measure?  Yes   No

18. Did you weigh?       Yes    No

To the best of my knowledge and belief, the answers recorder herin are true and complete

_______________________________               _______________

Signature of Patient                                                      Date

Preferred doctor consultation contact time? Circle One:

8am-11am    11am-2pm    2pm-5pm    5pm-8pm

_______________________________                ________________

Signature of Examiner                                                   Date

Examiner Use Only:

Examiner Name: (Please Print)

Examiner Phone Number:

Title/State Medical Lic. #

Place of Exam

(Circle One)

   Patient’s Home          Patient’s Office         Examiner’s Office