New Patient Information

New Patient Information
Date:

MonthDayYear
Date
Name:
Date of Birth:

MonthDayYear
Date
Age:
Sex:
Marital Status:
Email:
example@example.com
Address:
City/State/Zip#:
Home Phone:
Cell Phone:
Occupation:
Employer:
Work Phone:
Spouse/partner name:
Spouse/partner phone:
Who may we thank for referring you to our office?
What is the name of your medical doctor?
What is the phone number of your medical doctor?
Pharmacy Information
Preferred pharmacy (name and phone):
Health Information
Do you smoke cigarettes?

YesNo
Drugs to which you are allergic (what happens?):
Are you allergic to any of the following?

Adhesive tapeLatexOpiates (codeine, Percocet)AspirinAntibioticsLocal anestheticsSulfaIodine
Medications, vitamins, and supplements you take now
Please list the medication, dosage, frequency and purpose:
Please list any medical problems, including approximate dates of diagnosis:
Please list any plastic surgery you have had, including approximate dates:
Please list any other surgeries you have had, including approximate dates:

Have you been diagnosed with any of the following:

	NO	YES	IF YES, please describe
High blood pressure
Heart attack
Stroke or TIA (mini-stroke)
Blood clot (deep vein thrombosis, Pulmonary embolism)
Bleeding problems
Cancer
Kidney problems
Seizures
Psychiatric condition
Problems with anesthesia

Please describe what you would like to discuss with Dr. Levine:
Thank you for taking the time to fill out this form. I look forward to meeting you.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: