Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
 
 

Patient History

 
* Required Information
Tobacco Use
*What is your current cigarette smoking status?
*How many packs per day do you smoke?
*How many packs per day did you smoke?
*How many years have you been smoking?
*How many years did you smoke?
*Do any of these statements apply to you?
*Please mark any tobacco products that you use:
*Are you exposed to secondhand smoke?
Alcohol Use
*How often do you drink alcohol?
*Type(s):
Drug Use
*Do you have a dependency or addiction to drugs now or in the past?
*which one's?
*Do you use recreational drugs?
*which one's?
Caffeine Use
*Do you consume any of these?
*Servings per day:
Exercise
*Number of times you exercise each week:
*Type(s):
About You
*Home Living Setting
*Are you retired?
*What is your current or most recent occupation?
*What is your dominant hand?
Transfusions
*Will you accept transfusion of blood products?
Past Medical History
*Please indicate if YOU have a history of the following:
 
Family Medical History
*Please indicate which family members have had these illnesses:
Problems with Anesthesia
Cancer
Leukemia
Heart Disease
High Blood Pressure
Arthritis
Stroke
Diabetes
Bleeding/Clotting Problem
Current Symptoms
Please select only the symptoms you CURRENTLY are experiencing.
Select all that apply - if no symptoms, please select 'NONE'
*General
 
 
 
 
*Eyes
 
 
 
 
*Ear, Nose, and Throat
 
 
 
 
 
 
 
 
 
*Cardiovascular
 
 
 
 
 
 
 
 
*Respiratory
 
 
 
 
*Gastrointestinal
 
 
 
 
 
 
*Musculoskeletal
 
 
 
 
 
 
 
*Neurologic
 
 
 
 
 
 
 
 
 
*Endocrine
 
 
 
 
 
*Heme / Lymphatic
 
 
 
 
 
 
*Allergic / Immunologic
 
 
 
 
Allergies
*Are you allergic to any of the following?
Surgeries and Hospitalizations
*Have you ever had any problems with anesthesia (being numbed or put to sleep)?
*Have you had any surgeries?
*Please select how many surgeries you have had, and put in the name of the procedure and the year it was performed.
*Have you ever been hospitalized?
*Please select how many times you have been hospitalized, and the reason why as well as year.
Physician / Pharmacy info
*Name of Primary Care Physician
*Pharmacy Preference (include location)
 
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.