MAIN COMPLAINT:____________________________________________________________________
	
	How Long?__________________________________________________________________
	
	Was this due to an injury? ________________________________________________
	
	Have you had any X-Rays? __________________________________________________
	
	Have you had any other testing? (lab work, etc.) __________________________

PLEASE BRING OR LET US KNOW OF PERTINENT X-RAY FILMS, LAB RESULTS, 
OR SPECIAL TEST RESULTS

REFFERAL INFORMATION:
	
	Who suggested that you see us? ____________________________________________
	
	Who is your Primary Care Physician? _______________________________________


Instructions: Please answer ALL questions to the best of your ability. 
If you are unsure about an answer, leave it blank.

MEDICAL HISTORY:
Personal History - Circle Yes or No, if yes, when?		   
Asthma			yes	no	________	   
Tuberculosis		yes	no	________	   
Cancer			yes	no	________	   
Diabetes/Sugar		yes	no	________	   
Bleeding Disorders	yes	no	________	   
Heart Disease		yes	no	________	   
Kidney Disease		yes	no	________	   
Liver Disease		yes	no	________	   
High Blood Pressure	yes	no	________	   
Glandular Disorders	yes	no	________
Skin Disorders		yes	no	________
Neurologic Disorders	yes	no	________
Emotional Disorders	yes	no	________
Ulcer			yes	no	________
Other			yes	no	________

Family History - If yes, mother or father?
Asthma			yes	no	________
Tuberculosis		yes	no	________
Cancer			yes	no	________
Diabetes/Sugar		yes	no	________
Goiter			yes	no	________
Heart Disease		yes	no	________
Stroke			yes	no	________
Free Bleeder		yes	no	________
Deafness		yes	no	________

Please List all current medications: (please print!)

____________________________   _________________________________

____________________________   _________________________________

____________________________   _________________________________



Are you allergic to any medications? ________________    
If YES, please list below and the reaction you had to each:

________________    _______________________________________________

________________    _______________________________________________

________________    _______________________________________________



Please list all Operations:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________


Have you ever had a blood transfusion? _________ 

If yes, when?  _________________________________

Do you drink alcohol? ____________  

If yes, how much and how often? ___________________________________

Do you use tobacco? ____________  

If yes, type and how often you use it? ____________________________

How long have you used tobacco? ___________________________________

Have you used tobacco in the past? ________________   

Year you quit? ___________________________

Do you drink/use caffeine? (coffee, sodas, teas, drugs with caffeine)

 ____________  How much? ___________________________________________

List any additional information you wish to include in your medical 
record: 

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________











REVIEW OF SYMPTOMS - Answer the following by checking the symptoms 
which apply to you.

EARS:								

___ Pain						
___ Drainage or Discharge				
___ Itching					
___ Fullness or Blockage				
___ Difficulty hearing					
___ Dizziness					
___ Ringing or Noise					

			
NOSE:

___ Blockage
___ Stuffiness
___ Frequent Colds
___ Itching
___ Bad Odor
___ Pain or Tightness
___ Nose Bleeds			
___ Hay Fever
___ Frequent Snoring
___ Dryness


MOUTH AND THROAT:

___ Drainage down back of throat
___ Frequent sore throats
___ Dryness of the throat
___ Itching or tickling
___ Difficulty swallowing
___ Dental Problems
___ Lump, Pressure, Tightness
___ Burning Tongue
___ Bleeding Gums
___ Hoarseness
___ Frequent Throat Clearing


EYES:

___ Itching or Burning
___ Dryness
___ Swelling
___ Pain
___ Blurred Vision


GENERAL: 					
								
___ Frequent Headaches
___ Menstrual Irregularities
___ Nervousness
___ Fatigue easily		
___ Insomnia
___ Hot Flashes			
___ Palpitations		
___ Chest Pains			
___ Cough			


Patients Name: ______________________________________________________

Date: _________________