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New Patient Visit

It is important we have complete and accurate information about you and your medical condition. Please read instructions carefully and complete the following:

(*) Marked Fields Are Required

* Patient's Name:

* Sex:	* Age:
M F

Marital Status:

Single

Married

Widowed

Divorced

* Patient's Social Security :

* Residence Address:		* Home Phone:

* City:		* State:		* Zip:

Physician Information Please complete the following information for all physicians/healthcare providers you have seen within the past 5 years (starting with your Primary Care Provider).

Name

City

Specialty/
Problems

Dates Seen

May we send a summary of your visit to this Dr.?

Yes

I authorize (A-One Sleep Center, LLC.) , it's employees and/or agents, to forward my medical information (including psychologic, psychiatric, alcohol and drug abuse diagnosis and treatment information) to those persons marked "yes" above, and other healthcare providers who may be responsible for my continuing medical care.

Medication

Are you currently taking any prescription and/or non-prescription medications including vitamins, nutritional supplements, oral contraceptives, pain relievers, diuretics, laxatives, allergy medications and cold medications? If yes, list medications below.
Yes	No

Name of Medication

Dosage (mgs)

How often taken

Are there other medications you have recently used? If yes, list below.
	Yes		No

Do you have any allergies? If yes, list below.
	Yes		No

Have you had hives, skin rash, breathing problems or other allergic reactions to medication? If yes, list reactions below.
	Yes		No

Are there other medications you would prefer not to take because of prior side effects? If yes, list below.
	Yes		No

Past Medical History
Indicate whether you have ever had any of the following and if so, please describe the problems.

Anesthesia complications
	Yes		No

if yes describe

Anxiety, depression, mental illness
	Yes		No

if yes describe

Blood problems (bleeding, anemia, etc)
	Yes		No

if yes describe

Diabetes
	Yes		No

if yes describe

High blood pressure
	Yes		No

if yes describe

High cholestrol or triglycerides
	Yes		No

if yes describe

Sexually transmitted disease
	Yes		No

if yes describe

Stroke or TIA
	Yes		No

if yes describe

Treatment for alcohol or drug abuse
	Yes		No

if yes describe

Indicate whether you have ever had a medical problem and/or surgical problem related to each of the following. If so, describe the problem, type of surgery and approximate dates.

Eyes (cataracts, glaucoma)
	Medical		Surgical		No

describe

Thyroid, parathyroid glands
	Medical		Surgical		No

describe

Ears, nose, sinuses, tonsils
	Medical		Surgical		No

describe

Heart valves, rhythm and/or failure
	Medical		Surgical		No

describe

Coronary, heart attack, angina
	Medical		Surgical		No

describe

Arteries (aorta, arteries to head, arms, etc)
	Medical		Surgical		No

describe

Lungs
	Medical		Surgical		No

describe

Esophagus or stomach (ulcer)
	Medical		Surgical		No

describe

Appendix
	Medical		Surgical		No

describe

Bowel (small or large intestine)
	Medical		Surgical		No

describe

Liver or gall bladder
	Medical		Surgical		No

describe

Hernia
	Medical		Surgical		No

describe

Kidneys, bladder
	Medical		Surgical		No

describe

Bones, joints, muscles
	Medical		Surgical		No

describe

Back, neck, spine
	Medical		Surgical		No

describe

Brain
	Medical		Surgical		No

describe

Skin
	Medical		Surgical		No

describe

Breasts
	Medical		Surgical		No

describe

Uterus, tubes, ovaries
	Medical		Surgical		No

describe

Prostate, penis, testes, vasectomy
	Medical		Surgical		No

describe

Other - Describe
	Medical		Surgical		No

describe

Review of Systems
Indicate whether you have ever experienced the following symptoms during recent weeks. Indicate the symptom(s) when multiples are listed in a question.

Skin rash, sore excessive bruising
	Yes		No

if yes describe

Excessive thirst or urination
	Yes		No

if yes describe

Change of a mole
	Yes		No

if yes describe

Change in sexual drive or performance
	Yes		No

if yes describe

Significant headaches
	Yes		No

if yes describe

Diminished hearing, dizziness, hoarseness
	Yes		No

if yes describe

Sinus problem, asthma
	Yes		No

if yes describe

Cough, shortness of breath, wheezing
	Yes		No

if yes describe

Coughing up sputum or blood
	Yes		No

if yes describe

Blackouts or loss of conciousness
	Yes		No

if yes describe

Chest pain, pressure
	Yes		No

if yes describe

Rapid or irregular heart beats
	Yes		No

Awakening at night short of breath
	Yes		No

if yes describe

Abnormal swelling in legs or feet
	Yes		No

if yes describe

Pain in calves when you walk
	Yes		No

Difficulty swallowing, heartburn
	Yes		No

if yes describe

Nausea, vomiting, diarrhea
	Yes		No

if yes describe

Significant problems with constipation
	Yes		No

if yes describe

Blood in bowel movements
	Yes		No

if yes describe

Difficulty starting urinary stream
	Yes		No

if yes describe

Unable to completely empty bladder
	Yes		No

if yes describe

Leaking urine
	Yes		No

if yes describe

Burning or pain when urinating
	Yes		No

if yes describe

Pain, stiffness or swelling in back, muscles
	Yes		No

if yes describe

Fever, large lymph nodes
	Yes		No

if yes describe

At risk for HIV or AIDS
	Yes		No

if yes describe

Weight loss or gain of more than 100 lbs
	Yes		No

if yes describe

Experiencing an unusually stressful situation
	Yes		No

if yes describe

Problems falling asleep, staying asleep
	Yes		No

if yes describe

Sleep apnea, snoring
	Yes		No

if yes describe