Personal Information

Full Name

Date of Birth

Street Address

City

State

Zip Code

Telephone Number

Alternate Telephone Number

Height

Weight

Blood Type

Name of Employer

Street Address

Phone Number

City

State

Zip Code

Emergency Contact Information

Full Name

Relationship

Street Address

City

State

Zip Code

Home Phone Number

Cell Phone Number

Work Phone Number

Pager Number

Advance Healthcare Choices – Please be sure to bring a copy with you for your medical record

Yes

No

Yes

No

Advance Directive

Durable Power of Attorney

Consent to Blood Transfusion

Organ Donor

Do Not Resuscitate Order

Physician Information

Primary Care Physician’s Name

Street Address

Phone Number

City

State

Zip Code

Physician (Specialist) Name

Street Address

Phone Number

City

State

Zip Code

Primary Insurance Information

Primary Insurance Company

Policyholder’s Name

Relationship

Policyholder’s Date of Birth

Policyholder’s Phone Number

Policyholder’s Address

City

State

Zip Code

Policyholder’s Place of Employment

Policy Number

Group Number

Claims Mailing Address

City

State

Zip Code

Insurance Company Phone Number

Secondary Insurance Information

Secondary Insurance Company

Policyholder’s Name

Relationship

Policyholder’s Date of Birth

Policyholder’s Phone Number

Policyholder’s Address

City

State

Zip Code

Policyholder’s Place of Employment

Policy Number

Group Number

Claims Mailing Address

City

State

Zip Code

Insurance Company Phone Number

Allergies

Please list ALL known allergies, i.e. food, environmental factors, latex, etc.

Allergic to

Describe Reaction

Medications

Please list ALL medications including herbals, over-the-counter and prescription

Name of Medication

Dosage

Frequency

Immunization History

Immunization

Date Received

Immunization

Date Received

Hemophilus B

Pneumococcal

Hepatitis A

Polio

Hepatitis B

TB Skin Test

Influenza (Flu)

Tetanus (DPT, DT, dT)

Meningococcal

Varicella

MMR (Measles, Mumps, Rubella)

Other:  ______________

Medical History

Please check all that are applicable

None

Heart Attack

Rheumatic Fever

Arthritis

Heart Disease

Seizures

Asthma/Hay Fever

Hiatal Hernia/Reflux

Sleep Apnea

Bleeding

High Blood Pressure

Stomach/Bowel

Cancer

Infectious Disease

Stroke

Cataracts

Kidney Disease

Thyroid Disease

Diabetes

Liver Disease

Tobacco Use

Drug/Alcohol Abuse

Lung Disease

Ulcer

Fractures

Migraine Headaches

Yellow Jaundice

Glaucoma

Pacemaker

Blood Transfusion

Please give date(s):

Pregnancy(ies)

Please give date(s):

Previous Hospitalization(s)

Please give date(s):

Previous Surgery(ies)

Please specify/give date(s):

Problems with Anesthesia

Please specify:

Serious Illness/Injury(ies)

Please specify/ give date(s):

Additional Information