Online Patient Registration

HEALTH HISTORY
Please provide the following information:*
Age Weight Height
Past/current Hx (check all that apply)*
- Lung disease
- Liver disease
- Kidney disease
- Heart disease
- High blood pressure
- Mitral Valve Prolapse
- Chest pain
- Diabetes
- Asthma
- Hepatitis
- HIV
- Seizures
- Keloids
- MRSA/Staph
- Fever blisters
- Dry eyes
- Latex allergy
- Abnormal/excessive bleeding
- Taken Accutane within the past year
- Neck problems
- Sleep apnea
- Use CPAP/BPAP
- None of the above
Please list any medications you are currently taking, prescribed or over the counter.
Medication Name Reason for Taking Dosage/Frequency
Do you take any of the following? If yes, what?
Diet pills Natural herbs Health food supplements
Do you have any allergies and/or reactions to medication? If yes, please explain:
Please list any surgeries you have had and include the month / year:
Surgery Date
Have you or anyone in your family had complications from anesthesia?*
- Yes
- No
Have you been on any steroids in the last year? If yes, please explain:*
Do you take aspirin on a regular basis?*
- Yes
- No
Do you have excessive bleeding or bruising?*
- Yes
- No
Do you use any tobacco products?*
- Yes
- No
Are you pregnant?*
- Yes
- No
Other physicians caring for you:
Name Specialty Location
Preferred pharmacy:
Name Phone

First	Last

Daytime Phone:	Cell Phone:

Age	Weight	Height

Medication Name	Reason for Taking	Dosage/Frequency

PATIENT INFORMATION