Welcome to Our Office
Patient Name
Date of Birth
Did a Physician refer you?
Yes
No
If referred by Physician, Physician name:
If referral is other than a Physician, please indicate:
Friend
Family
Internet
Other
If selected "Other" for referral, indicate here:
List any family members seen by Dr. Ulrich:
Employer
Occupation
General Medical Information
Reason for today's appointment?
How long has this been a problem?
What prior treatment have you received for this problem?
Height
Weight
Social History
Marital Status:
Single
Married
Separated
Divorced
Widowed
Use of Alcohol:
Never
Rarely
Moderate
Daily
Do you smoke?
Never
Previously, but quit
Yes
If answered "Yes" to "Do you smoke?", how many packs per day?
Chewing tobacco:
Never
Previously, but quit
Yes
Use of Drugs:
Never
Previously
Yes
If answered "Yes" to "Use of Drugs", what type and frequency?
Excessive exposure at home or work to (check all that apply):
Fumes
Dust
Solvents
Noise
N/A
Allergies
Do you have any allergies to medication?
Yes
No
If medication allergies, please list them here:
Allergic to Latex?
Yes
No
Allergic to X-Ray Dye?
Yes
No
Medications
Please list all medications you are currently taking as well as their respective doses:
Medical History
Metabolic:
Diabetes
Yes
No
Blood Clots
Yes
No
Bleeding Problems
Yes
No
Anemia
Yes
No
Thyroid Disorders
Yes
No
Infectious Diseases:
A.I.D.S. - H.I.V.
Yes
No
Hepatitis (Jaundice)
Yes
No
Infectious Mono
Yes
No
Meningitis
Yes
No
Gastrointestinal / Renal:
Ulcers
Yes
No
Vomiting
Yes
No
Abdominal Pain
Yes
No
Kidney Disease
Yes
No
Heart Problems:
Myocardial Infarction (Heart Attack)
Yes
No
Angina (Chest Pain)
Yes
No
Arrhythmia (Skipped Beats)
Yes
No
Heart Murmur
Yes
No
Mitral Valve Prolapse
Yes
No
High Blood Pressure (Hypertension)
Yes
No
Neurologic:
Alterations in Vision (Glaucoma)
Yes
No
Seizures / Convulsions
Yes
No
Strokes / C.V.A.
Yes
No
Lung Problems:
Emphysema / COPD
Yes
No
Tuberculosis (T.B.)
Yes
No
Asthma
Yes
No
Shortness of Breath
Yes
No
Snoring/Sleep Apnea
Yes
No
Seasonal Allergies
Yes
No
Cancers / Tumors:
(please describe)
Surgical History
List any previous surgeries
Have you or any family member had a reaction to any local or general anesthetic?
Yes
No
Family History
High Blood Pressure
Lung Disease
Cancer
Diabetes
Kidney or Liver Disease
Stroke
Bleeding Disorders
Heart Disease
Other History
Hospitalizations
Signature (please sign with mouse):
Today's Date: