Patient Demographics

Please Complete This Document

If you do not complete this document online, you will be required to complete it when you arrive at our office.  We apologize for requesting some duplicate information.  

Todays Date*
Patient Name*
Date Of Birth*
Sex*
Marital Status*
Street Address*
Street Address Line 2

Family History

FAMILY HISTORY − List Immediate family members who have died (Father, Mother, etc.):

Check Illnesses immediate family members have had:

Patient History

Date Of Iast Dental Exam

Eye, Ear, Nose

Gastrointestinal

Cardio-Respiratory

EKG Last Date
Chest X-Ray Last Date

Genitourinary

Neuro-Muscular

Skeletal

Endocrine

Hematologic

Other

Tetanus Immunization Date

For Women Only

Last Menstrual Period Date
Last Pelvic Pap Smear Date

Patient History Continued

Please list all surgeries, hospitalizations, and/or serious injuries:

Please include all current prescriptions, over the counter meds, herbal, patches, inhaler, eye drops & supplements:

You are also advised to bring your complete list with you to your appointment.

Please name any drug allergies/adverse reactions:

Current Life Style:

Do You Use Alcohol More Than Four Times Per Week?*
Do You Smoke?*
Do You Ever Use Drugs Recreationally?*
Do You Feel Safe In Your Enviroment?*

Indicate any abnormality

Eyes
Ear Nose Throat
Skin
Nervous System
Chest
Heart
Abdomen
Genito Urinary System
Pelvic
Extremities
Back
Pain
0 = No Pain, 10 = Extreme Pain
Progress
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