PATIENT INFORMATION First Name: Middle name/inital Last Name: Address: City: State: Zip Code: Email Address: Home phone: Work phone: Cell phone: Date of birth: Male Female single married widowed divorced Occupation: Primary Care Provider: Are you required to have a referral to specialists? Yes No Who referred you to our office? Primary Insurance Insurance name Self Spouse Child Group number: Subscriber number: Secondary Insurance Insurance name Self Spouse Child Group number Subscriber number   HEALTH QUESTIONNAIRE What problem(s) are you having? How long has this been present? Please list all medications or bring in a list at your appointment: What allergies do you have? Do you smoke? No Yes Please check all that apply: AIDS/HIV Allergies to medications Allergies to anesthetics Anemia Arthritis Asthma Back Problems Cancer Chemical dependency Circulatory problems Diabetes Epilepsy Foot or leg cramps Gout Heart Problems Hemophilia Hepatitis High blood pressure Kidney problems Multiple sclerosis Liver disease Phlebitis (blood clot) Psychiatric care Stroke Swelling in legs and feet Skin ulcers Stomach ulcers Varicose veins Psoriasis Eczema MRSA Neuropathy Please list surgeries you have had. By entering my name here I certify that the above information is true to the best of my knowledge. By entering my name here I authorized Dr. Feller to bill my insurance company on my behalf. Anything else you would like us to know? Security code:   * Do not enter anything in this field:

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