n n n n trn n n x n trn trn n n n n n n n n n n n n n n n n

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n n n n trn n n x n trn trn n n n n n n n n n n n n n n n n
I
D^.TIENTMEDICALHISTORY
I
I
r.auenrs tt"
oru
ID:
Date of Last Visit:
Dateof Med.
Pleaseanswer the followi
Y N
Height:
n E Ooyousmokeor usetobacco?
DT
Y N Conditions
n D AbnormalBleeding
tr ! AlcohotAbuse
n n Albrgies
tr
tr
f]
n
n
tr
tr
tr
n
n
tr
n
n
n
n
tr
n
n
tr
n
n
n
n
D
n
tr
n
n
n
n
tr
n
n
tr
n
n
n
n
Anemia
Angina
Pectoris
Arthritis
ArtificialBones
Artificial
Heart
Vatve
Asthma
Blood
Transfusion
CancerChemotherapy
Colitis
Congenitat
Heart
Defect
Cosmetic
Surgery
Diabetes
Difficulty
Breathing
Drug
Abuse
Emphysema
Epitepsy
Fainting
Spells
Fever
Blisters
Frequent
Headaches
HeartRate:
Y N ConditionS
ND
NT
nn
nn
trn
nn
xn
DN
Ttr
TN
trn
trn
nn
nn
ND
TN
Ttr
Tf,
nf,
ntr
ntr
n!
Glaucoma
Hay Fever
HeartAttack
HeartSurgery
Hemophilia
HepatitisA
Hepatitis
B
HighBloodPressure
HIV+ AIDS
KidneyProblems
LiverDisease
Low BloodPressure
MitralValveProlapse
PaceMaker
Pneumocystitis
Psychiatric
Problems
Radiation
Therapy
Rheumatic
Fever
Serzures
Shiniles
SickleCellDisease
SinusProblems
Weight:
Conditions
ntr
NT
TN
TN
nn
nn
Y N
nn
nn
TD
nn
U!
trD
nn
DT
NT
Other
Stroke
ThyroidProblems
Tuberculosis
Ulcers
VenerealDisease
YellowJaundice
Allerqies
Aspirin
Codeine
DentalAnesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
J LJ l! there any disease,condition, or problom that you thlnk this office shoutd know about that ls not covered above?
lf yes, pleasedescribe below,,.
POLICIES
Your Appointment
is reservedand requiresa 48 hour noticeof canceltation.
We reserverheright to
chargea feeof $50for every% hour of missedappointments
for this time.
You agreethat we mayrelease
informationto theinsurance
carrie. regardingyour records.
Paymentis duewhenservices
are rendered.
All pastdueaccounts
of morethan30 daysaresubjectto a l.5olomonthlyfinancecharge.
MY SICNATUREBELOW INDICATESTHAT I HAVE READTHIS ENTIRE FORM, PROVIDED
CORRXCTINFORMATION,AGREETO THE CONDITIONSLISTEDABOVEAND THAT I
UNDERSTAND
THAT FILINC INSURANCE
CLAIMSIS MY RESPONSIBILITY.
PATIENT'S SIGNATURE
(lf minor,Parent/Guardian
must sign)
DATE
I, DR.PASSES,
HAVE REVIEWEDTHE MEDICAL HISTORY.
DOCTOR'S SIGNATURE
DATE

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