Health questionaire
(new patients only)

Please fill out this form:

Personal Information
Last Name
Birthday    (e.g. 1980)
Gender Male      Female
Marital Status married Single Widowed Divorced
Zip Code
Where and when would you like to visit us?
Date of Visit   AM PM
We will confirm your appointment within 24 hours !
Please answer the following questions. circle yes or no, whichever applies.

1. Has there been any change in your general health within the past year
No Yes

2. My last physical examination was on

3. Are you now under the care of another physician
No Yes
If so, what is the condition being treated

4. The name and address of another physician is

5. Have you had any serious illness or operation
No Yes

6. Have you been hospitalized or had a serious illness within the past five (5) years
No Yes
If so, what was the problem

7. Do you have or have you had any of the following diseases or problems. Check all that applies:
         a. Rheumatic fever or rheumatic heart disease
         b. Congenital heart lesions
         c. Cardiovascular disease(heart trouble, heart attack, coronary insufficiency, coronary                   occlusion, high bloodpressure, arteriosclerosis, stroke)
                1) Do you have pain in chest upon exertion
               2) Are you ever short of breath after mild exercise
               3) Do your ankles swell
               4) Do you get short of breath when you lie down, or do you require extra pillows                          when you sleep
         d. Allergy
         e. Sinus trouble
         f. Asthma or hay fever
         g. Hives or a skin rash
         h. Fainting spells or seizures
Is there anything else you would like us to know?
You may send your data now by clicking on the Submit button. The data you entered will be validated, then sent by email.
...or clear the form !
Revised March 2001; © otto-graph
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