Forms Patient Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Birthdate* Email* Phone*Sex*MaleFemaleOccupationPrimary PhysicianOffice PhoneOffice FaxAre you allergic to any medications? If so please list belowHave you ever had surgery?YesNoIf yes, what and when?Have you ever had any of the following problems? Blood Pressure Problems Heat Problems Diabetes Glaucoma Cataract Eye Problems Thyroid Skin Problems/Hives Anemia Convulsions Paralysis/Stroke Dizziness Migraines Shortness of breath Asthma Cancer Chronic Cough Kidney Problems Difficulty Urinating Ear Problems Sinus Problems Stomach Problems Throat Problems Liver Disease Arthritis Other If other, please explainDo you smoke?YesNoDo you drink?YesNoIf so, how much?123456789How often?DayWeekMonthCurrent medications you are taking regularly. Both name and dosage please.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.