This form is to be completed by one of the following: (Please check one)
 Date of Birth:
 Gender:
 Enter the email address (optional):
 Enter a personal ID Number to identify yourself (DO NOT use your SSN):
 Confirm personal ID Number (DO NOT use your SSN):
 Primary Care Physician:
Name:
Street:
City:
State:
Zip:
Phone:
 Height:
ft in
 Weight:
 Last Blood Pressure Reading: (Please enter all information)   
 Systolic BP: 
 Diastolic BP: 
 Pulse: 
 Race/Ethnicity: (Please check one)
 Disability Status: (Please check all that apply)   
Are you deaf or do you have serious difficulty hearing
Are you blind or do you have serious difficulty seeing, even when wearing glasses
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Do you have serious difficulty walking or climbing stairs?
Do you have difficulty dressing or bathing?
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
 Past Medical History: (Please check all that apply)   
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%
 Past Surgical History: (Please check all that apply)   
 General Health: (Please check all that apply)   
 Immunizations: (Please check all that apply)   
 Recreational Drug Use? (Please check one)   
 Drug(s) used? please describe:
 Special Diet: (Please check all that apply)   
 Cardiovascular: (Please check all that apply)   
 Head ♦ Eyes ♦ Ears ♦ Nose ♦ Throat: (Please check all that apply)   
 Respiratory ♦ Lungs: (Please check all that apply)   
 Stomach ♦ Bowels: (Please check all that apply)   
 Musculoskeletal ♦ Bones: (Please check all that apply)   
 Neurological ♦ Brain: (Please check all that apply)   
 Skin: (Please check all that apply)   
 Mental Health: (Please check all that apply)   
 Blood ♦ Lymph: (Please check all that apply)   
Date of procedure:
 Allergy ♦ Immune Problems: (Please check all that apply)   
 
 
Anaphylaxis
 
Confusion
 
Diarrhea
 
Itching or Rash
Nausea or Vomiting
Swelling
 
Other
 
 Endocrine: (Please check all that apply)   
 Genital ♦ Urinary ♦ Breast ♦ GYN: (Please check all that apply)   
Date of procedure:
Date of procedure:
Date Began:
How many:
How many born alive:
 Tobacco Use (Please check all that apply)   
 
    How long using? (Years)
    How much? (Per Day)
    If Quit, When? (Years)
 Cigarettes (Pack)
 Cigars (Each)
 Pipe (Bowlfuls)
 Chew Tobacco (Pouch)
 Other:
 (Quantity)
 Alcohol Use: (Please check all that apply)   
 
    How long using? (Years)
    How much? (Per Day)
    If Quit, When? (Years)
 Beer (12 oz)
 Wine/Cocktails (5 oz)
 Liquor/Mixed Drinks
(1.5 oz)
 Other:
 (oz)
 Implants: (Please check all that apply)   
Date of procedure:
 By Whom:
Date of procedure:
 By Whom:
Date of procedure:
 By Whom:
Date last serviced
 By Whom:
Date of procedure:
 By Whom:
Date last serviced
 By Whom:
Date of procedure:
 By Whom:
Date last serviced
 By Whom:
Date of procedure:
 By Whom:
Date last serviced
 By Whom:
Date of procedure:
 By Whom:
Date last serviced
 By Whom:
 Family History: (Please check all that apply)   
 High Blood Pressure 
 
 Coronary Artery disease 
 
 Diabetes 
 
 Seizures 
 
 Headaches/Migraines 
 
 Asthma 
 
 Heart Attack 
 
 Bowel Problems 
 
 Stroke 
 
 TB 
 
 Arthritis 
 
 Emphysema 
 
 Kidney Stones 
 
 Kidney Disease 
 
 Thyroid Problems 
 
 Osteoporosis 
 
 Problems with Anesthesia 
 
 Problems with Surgery 
 
 Pacemaker 
 
 Cancer 
 
Location(s)?
Location(s)?
Location(s)?
Location(s)?
 Family Members (Please check all that apply)
 Mother 
 Present Age 
 Age At Death 
 Cause of Death 
 Father 
 Present Age 
 Age At Death 
 Cause of Death 
 Brother(s)
 
Number Alive:
 
Number Deceased:
 Sister(s)
 
Number Alive:
 
Number Deceased:
 Local Pharmacy:
Name:
Phone:
Fax:
 Mail Order Pharmacy:
Name:
Phone:
Fax:
 Medications ♦ Reminders
 Example: Medication, Purpose, Dose, Times of day, Form, Special Instructions
 Comments:
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