Patient Intake form: Medical History "*" indicates required fields First Name* Last Name* Phone*Email* Age Date of Birth* MM slash DD slash YYYY Describe Your ProblemDate of onset of problem Month Day Year Name of Primary Care Physician Name of Any Other Physician(s) You're Seeing OperationsPlease list: Type of surgery, Approximate date of surgery, surgeon, hospital where surgery took place.Medical ConditionsPlease check if you are currently receiving treatment or have received treatment in the past: Anemia Arthritis Alzheimer Asthma Birth Defects Bleeding Problems Cancer Currently Pregnant Depression Diabetes Epilepsy Glaucoma Hearing Probelms Heart Disease Hepatitis High Blood Pressure Intestinal Pain Kidney Disease Migraines Phlebitis (blood clots) Rheumatic/Scarlet Fever Stroke STD Thyroid Disease Ulcers What medications are you taking for the medical conditions you checked off above? What dosage are you taking for the medical conditions you checked off above? Approximately how long have you been taking the medication(s)? Prescribing Physician Any drug allergies? Yes No Physical Reaction
