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3046 Dolphin Dr. Suite 104, Elizabethtown, KY 42701

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Enrollment Form

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Date of Birth*
Email*
Gender*
Marital Status*
Occupation*

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Emergency Contact*
Emergency Contact Phone*
Do you have health insurance?*
- Yes
- No
Policy #*
Group #*
Allergies*
- Yes
- No
What type of allergies?*
Medication List [prescription and over the counter] (name, dosage, how do you take it?) (Example: MEDICINE, 100mg, once daily) Enter none if you do not take any medications.*

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Have you been treated for the following conditions?
Hepatitis B Series
- Yes
- No
Gardasil Series
- Yes
- No
Chicken Pox Immunization or Disease
- Yes
- No
Pneumonia Shot / Pneumonia Booster
- Yes
- No
Recent Flu Vaccine
- Yes
- No
Normal TB Screening
- Yes
- No
Tetanus
- Yes
- No
If yes, when?

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Health Tests
Have you been treated for the following conditions?
Bone Density Test
- Yes
- No
Colonoscopy
- Yes
- No
If yes, when?
Eye Exam
- Yes
- No
If yes, when?
Mammogram
- Yes
- No
If yes, when?
Pap Smear
- Yes
- No
If yes, when?
Physical Exam
- Annual Physical
- DOT Physical
- Sport Physical
- No
Date of Last Physical Exam

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Health History
Tobacco Use
- Never Smoked
- Quit Smoking
- Smoker
If you are a smoker, how many packs per day do you smoke?
If you quit smoking, what year did you quit?
Caffeine
- Never
- 1-2 cups of coffee daily
- More than 2+ cups of coffee daily
- 1-2 glasses of caffeinated beverages daily
- More than 2+ glasses of caffeinated beverages daily
Alcohol
- Never
- Daily
- Weekends
- Socially on occasion
Recreational Drugs
- Never
- Daily
- Weekends
- Socially on occasion
Special Diet
- Yes
- No
If on a special diet, what type and reason?
Sexually Active
- Yes
- No

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Women's Health
Age of first menses
Menopause
- Yes
- No
Abnormal Pap
- Yes
- No
Painful Periods
- Yes
- No
Regular Periods
- Yes
- No
PMS Symptoms
- Yes
- No
Pain with intercourse
- Yes
- No
Content with sex life
- Yes
- No

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Women's Health
Number of Pregnancies
- 0
- 1
- 2
- 3+
Full-term Pregnancies
- 0
- 1
- 2
- 3+
Pre-term Pregnancies
- 0
- 1
- 2
- 3+
Miscarriages
- 0
- 1
- 2
- 3+
Abortions
- 0
- 1
- 2
- 3+
Tubals
- 0
- 1
- 2
- 3+
Cesarean Section
- Yes
- No
If yes, how many and what years?
Infertility Issues
- Yes
- No

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Health History
Have you been treated for any of the following conditions?
Heart
- Abnormal EKG
- Chest Pain
- Heart Attack
- Heart Disease
- High Blood Pressure
- Stroke
- Peripheral Vascular Disease
- None
Pulmonary
- Asthma
- Emphysema or COPD
- Obstructive Sleep Apnea
- Shortness of Breath
- Snoring
- None
Ears, Nose and Throat (ENT)
- Eye Problems
- Hearing Loss
- Sinus Problems
- None
Gastrointestinal
- Acid Reflux
- Constipation
- Crohn's Disease
- Diarrhea
- Hernia
- Irritable Bowel
- Gall Bladder Disease
- Liver Disease
- Pancreatitis
- None
Renal
- Erectile Dysfunction
- Kidney Disease or Stones
- STD
- Urinary Infections
- Urinary Incontinence
- None

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Health History
Check if you have or have had any of the following issues.
Musculoskeletal
- Gout
- Neck Problems
- Osetoarthritis
- Rheumatoid Arthritis
- Spinal / Back Problems
- None
Neuro/Psych
- ADD / ADHD
- Anxiety
- Concession
- Depression
- Epilepsy
- Headaches
- Memory Loss
- Migraines
- OCD
- Seizures
- Suicidal Thoughts or Attempts
- None
Hemotology
- Anemia
- Blood Clots
- Cancer
- Diabetes
- Pancreatitis
- Sickle Cell Disease
- Thyroid Disease
- None
Endocrine
- Diabetes
- Pancreatitis
- Sickle Cell Disease
- Thyroid Disease
- None
Skin
- Acne
- Eczema
- Melanoma
- Psoriasis
- Skin Disorders
- None
Surgeries
- Appendectomy
- Breast Biopsy
- Carpal Tunnel Surgery
- Cervical (Neck) Surgery
- Colonoscopies
- Cholecystectomy
- EGD (Esophagogastroduodenoscopy)
- Heart Cath
- Heart Stent
- Hernia Repair
- Hysterectomy
- Joint Replacement
- Myringotomy (ear tubes)
- Prostate Biopsy/Surgery
- Spine Surgery
- Thyroid Biopsy
- Tonsils (tonsils and adenoids)
- None

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Family History
Does your father have a history of medical problems?
- Yes
- No
If yes, check all that apply
- Asthma
- Bleeding Disorders
- Breast Cancer
- Colon Cancer
- Depression or Anxiety
- Diabetes
- Drug or Alcohol Addiction
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Leukemia
- Liver Disease
- Lung Cancer
- Osteoporosis
- Pancreatic Cancer
- Rheumatoid Arthritis
- Stroke
- Thyroid Disease
- Prostate Cancer
Does your mother have a history of medical problems?
- Yes
- No
If yes, check all that apply
- Asthma
- Bleeding Disorders
- Breast Cancer
- Colon Cancer
- Depression or Anxiety
- Diabetes
- Drug or Alcohol Addiction
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Leukemia
- Liver Disease
- Lung Cancer
- Osteoporosis
- Pancreatic Cancer
- Rheumatoid Arthritis
- Stroke
- Thyroid Disease
- Prostate Cancer
Does your sibling(s) have a history of medical problems?
- Yes
- No
- No siblings
If yes, check all that apply
- Asthma
- Bleeding Disorders
- Breast Cancer
- Colon Cancer
- Depression or Anxiety
- Diabetes
- Drug or Alcohol Addiction
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Leukemia
- Liver Disease
- Lung Cancer
- Osteoporosis
- Pancreatic Cancer
- Rheumatoid Arthritis
- Stroke
- Thyroid Disease
- Prostate Cancer
Does your child/children have a history of medical problems?
- Yes
- No
- No children
If yes, check all that apply
- Asthma
- Bleeding Disorders
- Breast Cancer
- Colon Cancer
- Depression or Anxiety
- Diabetes
- Drug or Alcohol Addiction
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Leukemia
- Liver Disease
- Lung Cancer
- Osteoporosis
- Pancreatic Cancer
- Rheumatoid Arthritis
- Stroke
- Thyroid Disease
- Prostate Cancer

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Terms of Service
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- I have read and agree to the Terms of Service for this clinic

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