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Patient Information



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 Male  Female

 African American  Asian  Native Hawaiian  Latino or Hispanic  American Indian or Alaska Native  Caucasian/White  Non-Latino or Non-Hispanic  Prefer not to answer




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Primary Care Physician





Past Medical History

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ROS - (Please check all CURRENT positive findings)

Weight Loss Fevers Chills Poor Appetite Fatigue Weight Gain Insomnia Night Sweats
Blurry Vision Eye Pain Eye Discharge Eye Redness Decrease in Vision Dry Eyes Double Vision
Sore Throat Hoarseness Ear Pain Hearing Loss Ear Disharge Nose Bleeds Tinnitus Sinus Problems
Chest Pain Palpitations Rapid Heart Rate Heart murmur Poor Circulation Swelling in the legs or feet
Shortness of Breath Chronic Cough Coughing up Blood History of Tuberculosis Excess sputum Production
Nausea Vomiting Diarrhea Constipation Blood in the stool Frequent Heartburn Trouble Swallowing
Increased urinary frequency Blood in the Urine Incontinence Painful Urination Urinary Retention Frequent UTIs
Rash Hives Hair Loss Skin sores or ulcers Itching Skin thickening Nail Changes Mole Changes
Joint Pain Muscle aches Hair Loss Skin sores or ulcers Itching Skin thickening Nail Changes Mole Changes
Anxiety Depression Alcohol or Drug Dependence Sucidal Thoughts Panic Attacks Use of anti-depressants
Goiter Heat Intolerance Cold Intolerance Increased Thirst Change in Skin Pigment Excess Sweating
Seizures Tremors Migraines Numbness Dizziness/Vertigo Loss of Balance Slurred Speech Stroke
Low Blood Count Easy Bruising Swollen Lymph Nodes Transfusions Prolonged Bleeding Blood Clots
Allergic Reactions Hay Fever Frequent Infections Hepatitis HIV Positive Positive Tuberculin skin Test(PPD)

Social History


 Never Smoked  Ex-Smoker  Current Smoker


 Never  Occasional  Frequent

Family History - Please List any known medical problems



Primary Emergency Contact







Secondary Emergency Contacts







Primary Insurance Carrier




Secondary Insurance Carrier




Consent to treat Minor - Father Information








Consent to treat Minor - Mother Information








Consent to treat Minor - Guardian Information