Patient Registration

First Name

Middle Name

Last Name

Date of Birth

Sex

Male Female

Mailing Address

Phone Number(s)

Email Address

Occupation

Employer

Work Phone

Emergency Contact

Phone Number

Relationship to Patient

Insurance Information

Primary Insurance Plan

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

Secondary Insurance Plan (if any)

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

Functional Impact

Activities you can no longer perform:

Sports or hobbies affected (if applicable):

Pregnancy status:

No Yes Unsure

If unsure, last menstrual period date:

History of Cancer:

No Yes (Specify type and year: )

Medications and Allergies

Currently taking medications:

No Yes (List: )

Taking vitamins or supplements:

No Yes (List: )

Allergies to medications/foods/anesthetics:

No Yes (List: )

Bloodborne disease (Hepatitis B, C, HIV):

No Yes (List: )

Past Medical History

Condition	Yes	No
Allergies
Asthma
Congestive Heart Failure
Heart Disease
Stroke (CVA)
High Blood Pressure
Diabetes
Kidney Disease
Thyroid Problems
Lung Cancer
Seizures/Epilepsy
Osteoporosis
Arthritis
Gastritis/Stomach Ulcers
Inflammatory Bowel Disease
Depression
Anxiety
Urinary Incontinence
Other:

Review of Symptoms

Symptom	Yes	No
Fever
Chills
Weight Loss
Dizziness
Headaches
Vision Problems
Ringing in the ears
Difficulty Swallowing
Heartburn/Reflux
Constipation
Diarrhea
Shortness of Breath
Chest Pain
Palpitations
Night Sweats
Chronic Cough
Fatigue
Abdominal Pain
Numbness in Genitals

Consent and Office Policies

Patient Signature:

Sign here

Date:

Guardian Signature (if applicable):

Sign here (if applicable)

Date:

Patient Registration and Questionnaire