Dr. Doug Worful - Existing Patient Updates

Please check ALL that applies to your health.

Alcohol Use *

Yes No

Frequency *

Daily Weekly Monthly

Anemia *

Yes No

Anticoagulant Blood Thinner *

Yes No

Arthritis *

Yes No

Anxiety *

Yes No

Artificial Joints *

Yes No

Type:

Date:

Allergies to ANY Meds *

Yes No

If "Yes" Please List *

Asthma *

Yes No

Autism *

Yes No

Birth Control *

Yes No

Blood Disease *

Yes No

Bruises Easily *

Yes No

Cancer *

Yes No

Chest Pain *

Yes No

Chemo / Radiation *

Yes No

Chronic Cough *

Yes No

Cold Sores / Fever Blisters *

Yes No

Diabetes Type 1 *

Yes No

Diabetes Type 2 *

Yes No

Dizziness *

Yes No

Epilepsy

Yes No

Emphysema / COPD *

Yes No

Excessive Bleeding *

Yes No

Fainting *

Yes No

Gastric Reflux *

Yes No

Glaucoma *

Yes No

Hay Fever *

Yes No

Head Injuries *

Yes No

Heart Attack *

Yes No

Heart Murmur *

Yes No

Heart Stint *

Yes No

Hemophilia *

Yes No

Hepatitis A, B *

Yes No

Hepatitis C *

Yes No

High blood pressure *

Yes No

Medication: *

High Sugar Consumption *

Yes No

HIV/AIDS *

Yes No

HPV *

Yes No

HPV Vaccination *

Yes No

Iodine Allergy *

Yes No

Jaundice *

Yes No

Kidney Disease / Condition *

Yes No

Latex Allergy *

Yes No

Liver Disease

Yes No

Lupus *

Yes No

Mental Disorder *

Yes No

Mitral Valve Prolapse *

Yes No

Neurological Disorder *

Yes No

Nursing *

Yes No

Pace Maker *

Yes No

Pregnancy *

Yes No

Pre medication *

Yes No

Respiratory Problems *

Yes No

Rheumatic Fever *

Yes No

Sleep Apnea / C-PAP *

Yes No

Sinusitis *

Yes No

Snoring *

Yes No

Stroke *

Yes No

Tetracycline *

Yes No

Hyperthyroidism *

Yes No

Hypothyroidism *

Yes No

TMJ *

Yes No

Tobacco Use *

Yes No

Frequency *

Daily Monthly Yearly

Tuberculosis *

Yes No

Tumors *

Yes No

Ulcers *

Yes No

Other

Please explain any checked yes above

If anything else applies to your health that was not listed above, please list and explain

Medication List

Are you taking any medication? *

Yes No

Please list all medications you are taking and the reason for taking them. ( Click on + to add more ) *

Thank you for providing information, so we can provide the best care for you.

Patient Signature (or if Patient is a minor, Parents Signature) *

Clear

Patients Name *

First Name Last Name

Date *

Date