Name   Today's Date  
Age    Birthdate   Date of last physical examination
Emergency Contact:  Cell:  Home:   Office:

Symtoms (click on symptoms you currently have or have had in the past year)
GENERAL Chills Depression Dizziness Fainting Fever Forgetfulness Headache Loss of sleep Loss of weight Nervousness Numbness Sweats MUSCLE/JOINT/BONE Pain, weakness, numbness in: Arms Back Feet Hands Hips Legs Neck Shoulders GENITO-URINARY Blood in urine Frequent urination Lack of bladder control Painful urination	GASTROINTESTINAL Appetite poor Bloating Bowel changes Constipation Diarrhea Excessive Gas Hemmorhoids Indigestion Nausea Rectal bleeding Stomach pain Vomiting Vomiting blood CARDIOVASCULAR Chest pain High blood pressure Irregular heart beat Low blood pressure Poor circulation Rapid heart beat Swelling of ankles Varicose veins	EYE, EAR, NOSE, THROAT Bleeding gums Blurred vision Crossed eyes Difficulty swallowing Double vision Earache Ear discharge Hay fever Hoarseness Loss of hearing Nosebleeds Persistent cough Ringing in ears Sinus problems Vision - Flashes Vision - Halos SKIN Bruise easily Hives Itching Change in moles Rash Scars Sore that won't heal	MEN only Breast lump Erection difficulties Lump in testicles Penis discharge Sore on penis Other WOMEN only Abnormal Pap Smear Bleeding between periods Breast lump Extreme menstrual pain Hot flashes Nipple discharge Painful intercourse Vaginal discharge Other Date of last menstrual period ...... Date of last Pap Smear .............. Have you had a mammogram? ....... Are you pregnant? .... Number of children ....
Conditions (click on symptoms you currently have or have had any of the conditions below in the past)
AIDS Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts	Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herpes	High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio	Prostate Problem Psychiatric Care Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Typhoid Fever Ulcers Vaginal Infections Venereal Disease

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FAMILY  HISTORY Fill in health information about your family.  (All information is strictly confidential)
Relation	Age	State of Health	Age at Death	Cause of Death	Click if your blood relatives had any of the following:
					Disease		Relationship to you
Father						Arthritis, Gout
Mother						Asthma, Hayfever
Brothers						Cancer
						Chemical Dependency
						Diabetes
						Heart Disease, Strokes
Sisters						High Blood Pressure
						Kidney Disease
						Tuberculosis
						Other

HOSPITALIZATIONS					PREGNANCY  HISTORY
Year	Hospital	Reason for Hospitalization and Outcome			Complications if any
					HEALTH HABITS  Click which substances you use and describe how much you use
						Caffeine
Have you ever had a blood transfusion?     Yes   No If yes, please give appropriate dates:						Tobacco
						Drugs
SERIOUS ILLNESSES/INJURIES			DATE	OUTCOME		Other
					OCCUPATIONAL CONCERNS  Click if your work exposes you to the following:
						Stress
						Hazardous Substances
						Heavy Lifting
						Other
					Your occupation:

Do you have an Advanced Directive or Living Will?   Yes   No
I certify that the above information is correct to the best of my knowledge.  I will not hold my doctor or any members of his/her
staff responsible for any errors or omissions that I may have made in the completion of this form

By clicking below:
1. I agree to all the statements set out above
2. I warrant that I am the individual stated in this application and am authorized to request and approve these services
3. I agree to submit this registration to you electronically