Online Registration Form

Patient Information:

Sex:
May we leave a message on an answering machine or with a family member?
May we email or mail you information on services offered by our office?
MARITAL STATUS
SPOUSE:

PATIENT EMPLOYMENT INFORMATION:

PRIMARY INSURANCE:

EMERGENCY CONTACT INFORMATION :
(a relative or friend not living with you):

MEDICAL QUESTIONNAIRE:

Please check additional areas of concern that you would like to discuss with Dr. Gupta:

Body:
Face & Neck:
Other:
SERIOUS MEDICAL PROBLEMS:
CURRENT MEDICATIONS:

Medication One
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Two
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Three
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Four
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Five
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Six
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Seven
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Eight
Name of Medication:
Dose:
How often:
Date Last Taken:
DO YOU TAKE ASPIRIN ON A REGULAR BASIS?
DO YOU HAVE A PACEMAKER?
ALLERGIES:

Are you allergic to any medication?
What type of reaction do you have?
Do medications have an unusual effect on you?
Are you allergic to adhesive tape?
Are you allergic to iodine?
Please list any other allergies:
HABITS:
Do you have alcoholic beverages more than 2‐3 times per week?
Do you smoke?
How many packs per day?
How many years?
PAST SURGICAL HISTORY:

Procedure One
Date
Procedure
Surgeon
Procedure Two
Date
Procedure
Surgeon
Procedure Three
Date
Procedure
Surgeon
Procedure Four
Date
Procedure
Surgeon

MEDICAL QUESTIONNAIRE:

PAST MEDICAL HISTORY:
Have you ever had any of the following?:
REVIEW OF SYSTEMS:
Do you now or have you had within the past year any of the following?:
FAMILY HISTORY:
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Has anyone in your family had a tendency to bleed extensively?
Has anyone in your family had an unusual reaction to anesthesia?
Has anyone in your family had unexplained fevers following surgery?
Have you ever had a blood transfusion?
Do you have any metal in your body?
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