General Registration FormPersonal DataFirst Name *Middle NameLast Name *Email Address *Home Phone *Work/Cell PhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDate of Birth *HeightWeightEmployerEmergency ContactEmergency PhoneMarital StatusMarriedWidowedSeparatedDivorcedSingleOtherPrimary Care PhysicianNamePhone/FaxStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePresent SymptomsPlease briefly describe your symptoms.What do you feel is the most important factor to your present symptoms?Past Medical HistoryPlease list dates and diagnoses, illnesses, accidents (1 per line).Please list dates and surgeries (1 per line).Social HistoryPlease remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.Do you smoke cigarettes now? If yes, how many packs per day?Have you smoked in the past? If yes, how many total years have you smoked?Do you drink alcohol? If yes, how many drinks and what type of alcohol (beer, wine, spirits, etc.) do you have in an average week?Family HistoryPlease list ALL illness(heart disease, stroke, diabetes, hypertension, cancer (breast, cervical, skin, prostate, lung, blood), etc. If a member is deceased, please list age of death and cause if known.MotherFatherBrother(s)Sister(s)ChildrenSpouseMedicationsPlease list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.MedicationsAllergiesAre you allergic to any MEDICATIONS (Prescription or OTC)?Send Form
