Enrollment Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Gender*MaleFemaleMarital Status*SingleMarriedDivorcedWidowedOccupation* Emergency Contact*Emergency Contact Phone*Do you have health insurance?*YesNoPolicy #*Group #*Allergies*YesNoWhat 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.* Have you been treated for the following conditions?Hepatitis B SeriesYesNoGardasil SeriesYesNoChicken Pox Immunization or DiseaseYesNoPneumonia Shot / Pneumonia BoosterYesNoRecent Flu VaccineYesNoNormal TB ScreeningYesNoTetanusYesNoIf yes, when?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Health TestsHave you been treated for the following conditions?Bone Density TestYesNoColonoscopyYesNoIf yes, when?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Eye ExamYesNoIf yes, when?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MammogramYesNoIf yes, when?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pap SmearYesNoIf yes, when?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physical ExamAnnual PhysicalDOT PhysicalSport PhysicalNoDate of Last Physical ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Health HistoryTobacco UseNever SmokedQuit SmokingSmokerIf you are a smoker, how many packs per day do you smoke?If you quit smoking, what year did you quit?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CaffeineNever1-2 cups of coffee dailyMore than 2+ cups of coffee daily1-2 glasses of caffeinated beverages dailyMore than 2+ glasses of caffeinated beverages dailyAlcoholNeverDailyWeekendsSocially on occasionRecreational DrugsNeverDailyWeekendsSocially on occasionSpecial DietYesNoIf on a special diet, what type and reason?Sexually ActiveYesNo Women's HealthAge of first mensesMenopauseYesNoAbnormal PapYesNoPainful PeriodsYesNoRegular PeriodsYesNoPMS SymptomsYesNoPain with intercourseYesNoContent with sex lifeYesNo Women's HealthNumber of Pregnancies0123+Full-term Pregnancies0123+Pre-term Pregnancies0123+Miscarriages0123+Abortions0123+Tubals0123+Cesarean SectionYesNoIf yes, how many and what years?Infertility IssuesYesNo Health HistoryHave 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 Health HistoryCheck 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 Family HistoryDoes your father have a history of medical problems?YesNoIf 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?YesNoIf 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?YesNoNo siblingsIf 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?YesNoNo childrenIf 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 Terms of Service Click here for Terms of Service* I have read and agree to the Terms of Service for this clinic