Patient's Name: Birth Date:
Address:
Address continued:
Home Phone:

Social Security Number:
Driver's Licence Number State:
Employer: Occupation:
Marital status: Birth date of spouse:
Name and address of responsible party if different from above:
Phone number of responsible party:

Health insurance information

 

Name of Primary Insurance Company
Group Number Identification Number
Complete address if other then Medicare or NJ Blue Cross
Phone Number of Insurance Company if Authorization is Required
Referred to Office By:

Name

Date

Personal physician's name?

Reason for visiting doctor?
Age? Birth date?
Marital status? Number of children?
Type of employment?
List all past operations, major illnesses and injuries:
Check any of the following illnesses you have or have had:
Asthma
Bleeding
Cancer
Diabeted
Glaucome
HIV		 Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Pleurisy		 Pneumonia
Rheumatic Fever
Turberculosis
Stomach Ulcer
Yellow Jaudice
Are you disturbed by any of the following:
Headaches
Vision
Hearing
Dizzy spells
Chest pain
Cough		 Shortness of breath
Swelling of ankles
Appetite loss
Weight change
Constipation
Diarrhea		 Urinary Frequency
Painful urination
Urinary urgency
Difficulty walking
Leg cramps
Varicos veins
Are you presently anticoagulated? yes
no		 What drug?
Are you regularly taking asprin or an asprin related product? yes
no		 What drug?
How often?
List all other medication (including vitamins) you are taking now:
List any drug allergies
Do you have dentures? yes no
Do you wear glasses? yes no
Do you wear contacts? yes no
Do you smoke? yes no
What do you smoke?
How much do you smoke?
How many years have you quit?
Do you drink alcoholic beverages? yes no
What do you drink?
How much do you drink?

For female patients only

Date of last menstrual period? Are periods regular? yes no
Total number of pregnancies? Number of living children delivered:
Have you ever taken hormone drugs? yes no
Birth control pills name
Name
Other hormone drugs
Name
For what reason?
Name of Gynecologist
(if any)?
Which doctor would you like to see?
Dr. R.V. Ballem
Dr. Padma Alli