Patient Information and Intake Form

Patient Information and Intake Form
Date*
Name*

First and Middle NameLast Name
DOB*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell number*
Please enter a valid phone number.
Home telephone
Please enter a valid phone number.
Email*
example@example.com
OK to Email or Leave Message?*

YesNo
Occupation*
How did you hear about us?*
Ethnic Background*
Marital Status*

MarriedSingleDivorcedWidowLiving with significant other
Emergency Contact Information
In case of emergency please contact: blanks*.
Relationship to you: *.
Contact number: *.
Current Medical History
Please state the reason(s) for your visit and describe any symptoms you are experiencing:*
Hospitalizations/Surgeries (including tonsils, gallbladder, appendix, cosmetic). Please include the procedure and the year:*
Medications/Supplements. Please include the medication/supplement, the reason for taking, the date began, and the dose:*
Have you had an allergic reaction to local anesthetics (ex: Lidocaine)?*

YesNo
If Yes, please explain:
Have you had an allergic reaction to Penicillin or other antibiotics?*

YesNo
Have you had an allergic reaction to sulfa drugs?*

YesNo
Have you had an allergic reaction to latex?*

YesNo
Have you had an allergic reaction to sedatives?*

YesNo
Have you had an allergic reaction to iodine?*

YesNo
Have you had an allergic reaction to aspirin?*

YesNo
If yes, please explain:
Have you had an allergic reaction to drugs?*

YesNo
If yes, please explain:
Have you had an allergic reaction to food?*

YesNo
If yes, please explain:
Have you had any other allergic reaction? If yes, please list what happens:*
Please list any relevant family history:*
Do you use steroids?*

YesNoPass
If yes, for what condition and dosage?
Do you smoke?*

YesNoPass
If yes, how much per day?
**Smoking in any amount compromises the healing process and may negatively affect the outcome of your treatment.
Do you use analgesics?*

YesNoPass
Do you drink caffeine?*

YesNoPass
If yes, how many ounces per day?
Do you drink alcohol?*

YesNoPass
If yes, how much per week?
Do you use recreational drugs?*

YesNoPass
Please select any of the following that you ever had or are currently experiencing:

AcneAnorexiaAnemiaAsthmaBleeding TendencyBlood DisorderBruising TendencyCancer- ActiveCancer- RemissionCardiac DisorderCold SoresCurrent Cold/FluDiabetesEpilepsy/SiezuresHepatitis Type __High Blood PressureHigh CholesterolHIVInfection CurrentlyKidney DiseaseLeukopeniaLiver DiseaseLow Blood PressureLupus / SLELymph DisorderMigrainesMultiple SclerosisPacemaker/Electrical ImplantPoor Wound HealingRespiratory ArthritisRheumatoid ArthritisRaynaud'sSclerodermaShinglesSjogren'sSkin Rash CurrentlyStaph Infection/MRSAStrokeThyroid DisorderOther
If you answered YES to any of the above questions, please state how this medical condition is being managed. Name of Physician, Name of Medications, other Treatments, etc.
I attest that the above information is accurate to my knowledge and will alert BTL if any information about my health changes.
Patient Signature*

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Date*

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Date
Witness Signature

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Date

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Date
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Patient Information and Intake Form

Emergency Contact Information

Current Medical History