Pre-Registration


HEALTH MAINTENANCE – List the most recent date for each of the following:

WOMEN ONLY

BOTH MEN AND WOMEN

MEN ONLY


CONDITIONS – Check conditions you currently have or have had in the past.


ALLERGIES – Check appropriate box below. If yes, please list all known allergies to medications or substances.


MEDICATIONS – List all medications you are currently taking, including the dose and frequency:


HEALTH HABITS – Check the appropriate boxes below and describe


PREGNANCY HISTORY

List of Children


SURGICAL HISTORY


OTHER HOSPITALIZATIONS, SERIOUS ILLNESSES, INJURIES


FAMILY HISTORY – Fill in information about your family below:

Father

Mother

Brothers

Sisters

Check if a blood relative has had any of the following:

Disease

Relationship to you


ADDITIONAL INFORMATION – What else do you think your doctor should know about your health?

I certify that the information on this form is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that may have made in the completion of this form.