For Your First Visit

Practitioner:
Date:
Referral Source:

Personal Information

First Name:
Last Name:
M.I.:
Date of Birth:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Social Security#:
Gender:
Marital Status
Employer Name/Occupation:
Name of Insurance Co. & member #:
Family or Primary Care Physcian name :
Physcian Address:
Physcian Phone:
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Address:
Emergency Contact Home Phone:
Emergency Contact Bus. Phone:
Is today's Illness Job Related?
Date of Accident/Injury :
Type of Accident/Injury :
Purpose of visit:

Indicate yes or no, amount & frequency as appropriate

Cigarettes:
Caffeine:
Alcohol:
Water:
Food cravings, (ie. sugar, chocolate, salt):
Exercise:
If no, why not?:
Meditation/Yoga?:
List Medications:
List Vitamins / Supplements:
Phone:

Personal Health History(Check ones that apply)

Asthma:
Allergies:
Sinus problems/infections:
Migraines :
Headaches:
Diabetes:
High blood pressure:
High cholesterol levels:
Stroke:
Depression:
Eating disorder:
Alcoholism:
Drug addiction:
Arthritis:
Osteoporosis:
Osteopenia:
Cancer:
Gallbladder disease or Gall stones:
Kidney disease/stones:
Thyroid disease:
Seizures:
HIV/AIDS:
Hepatitis:
Neurological disease:
Autoimmune disorder:
Menopausal symptoms:
PMS:
Explanation/Comments:
Other Diagnosis:
Surgeries/Dates:

Family History:
How many of your blood relatives
(parents, grandparents, siblings, aunts, uncles, children)
have had the following?

Asthma:
Allergies:
Migraines :
Headaches:
Diabetes:
High blood pressure:
High cholesterol levels:
Stroke:
Depression:
Eating disorder:
Alcoholism:
Drug addiction:
Arthritis:
Osteoporosis:
Osteopenia:
Cancer:
Gallbladder disease or Gall stones:
Kidney disease/stones:
Thyroid disease:
Seizures:
HIV/AIDS:
Other:
Comments:

 

 

 

 

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