Demographics:

DOB: _____ / _____ / ________                           Gender:  M / F / TG / Other                    SS#: ______ - ____ - _________

Last Name: ________________________________________     First Name: _________________________     MI: ______

Nick name/ Preferred name: ________________________________________________

Residence address: _____________________________________________________________________

Mailing address: _______________________________________________________________________

Home Phone: (        ) ____________________________      Work Phone: (        ) ___________________________

Cell Phone: (        ) ______________________________     Email: _______________________________________

Occupation: ___________________________________      Employer/School: ______________________________      

Emergency Contact Person/Number/Relationship: ______________________________________________________________________

Do you have a living will? Y / N            Do you have a Power of Attorney (POA)?  Y / N  Whom?: _________________________________

Insurance Plan(#1): ______________________________________    Insurance Plan(#2): ____________________________________

Group No./ID No.: _______________________________________  Group No./ID No.: ____________________________________
_______________________________________________________________________________________________________________

Medical History: (circle all that apply)

High blood pressure / Hypertension          CAD /  “Heart attacks” / “Chest Pain”                    CHF / “Heart Failure”                            

Diabetes / ”High blood sugar”                  Asthma                                                                   COPD /  Emphysema

Kidney disease                                        Liver disease / Hepatitis (type? _____  )                  CVA / Stroke

Anemia / blood disease                           Thyroid disease                                                       Obesity / Overweight

Alcohol dep / addiction                           Tobacco dep / addiction                                          Drug dep / addiction

Depression                                              Anxiety                                                                   Bipolar disorder

Chronic pain (where? _____________________________________________   )              Neuropathy

HIV / AIDS                                            Hyperlipidemia / ”High cholesterol”                          Cancer (type? _______________________ )

Other medical conditions: _______________________________________________________________________________________________

Allergies: Penicillin / Sulfa / Others : ______________________________________________________________________________________

Surgical History: Appendectomy / Cholecystectomy / CABG / back surgery / Others: _______________________________________

Social History:    Do you smoke? Y / N             Did you ever smoke? Y / N    How many packs each day? _____      How many years? ______

Do you drink? Never / Seldom / Sometimes / Regularly                         Is alcohol a problem? Y / N                           Are you in AA? Y / N           

Which drugs do you do? __________________________________    Have you ever had treatment for addiction? Y / N

Married / Single / Domestic partner / Divorced / Separated?   How many times pregnant? _______                      Number of children?: ____
 

Family History:
High blood pressure / Hypertension         Coronary artery disease / “Heart attacks”                CHF / “Heart Failure”                            

Diabetes / ”High blood sugar”                  Asthma                                                                   COPD /  Emphysema

Kidney disease                                        Liver disease / Hepatitis (type? _____  )                 CVA / Stroke

Anemia / blood disease                           Thyroid disease                                                       Obesity / Overweight

Alcohol dep / addiction                           Tobacco dep / addiction                                          Drug dep / addiction

Depression                                              Anxiety                                                                   Bipolar disorder

Chronic pain (where? _____________________________________________   )              Neuropathy

HIV / AIDS                                            Hyperlipidemia / ”High cholesterol”                          Cancer (type? ___________________________ )

Other medical conditions: ____________________________________________________________________________