PATIENT INFORMATION Date Last Name Date of Birth Address Home Phone Number Employer First Name Middle Initial Age Social Security Number City State Zip Other Phone Number Work Phone YES NO

A. Are you pregnant? If yes, please stop and return to the front desk. B. Are you on ANY type of steroids (oral, inhaler, injections or creams)? Have you been on steroids within the past 3 weeks? C. Have you had an organ transplant? D. Have you had cancer? Are you in remission? E. Do you have any implanted electronic devices?

YES YES YES YES YES YES

NO NO NO NO NO NO

Can we leave a message on your answering machine? YES NO May we contact you at work? YES NO May we give results at this address? YES NO Would you like to receive occasional informational notifications? If so please provide address: Email Authorization to release information to and relation. Your Primary Care Physician Is: Have you ever filed legal actions against a healthcare provider? YES NO EMERGENCY CONTACT INFORMATION Last Name First Name Phone Number(s): Nearest Relative/Friend Not Living With You: Phone Number(s): Middle Initial

Above information will be used for verification and emergency purposes only. How Did You Hear About Laser Med Center? Patient Signature: _____

INITIAL CONSULTATION AND PATIENT HISTORY Circle any of the following which apply: - Arthritis - Compression Fracture - Diabetes - Kidney Failure/Dysfunction - Liver Failure/Dysfunction - High Blood Pressure - Irregular Heart Beat - Light Sensitivity - Lymphedema - Migraine Headaches Do you have a(n) infectious disease(s)?

- Neuropathy - Osteoarthritis - Rheumatoid Arthritis - Fibromyalgia - Asthma/Bronchitis - Gout - Stomach Ulcers/Reflux - Shingles - Lupus - Lyme Disease YES NO

- Heart Attack - Poor Circulation - Seizures - RSD/Causalgia - Heart Murmur - Scoliosis - Thyroid Disorder - Stroke - Tension Headache - Other