WELCOME

Welcome to Body By Bloch. Please fill out the following forms to the best of your ability. Fill out both forms and DO NOT SUBMIT either form until it has been reviewed by Dr. Bloch.

Patient Information

Today's Date required

Patient Name

First

Middle

Last

Patient Address

Street & Apartment #

City

State

Zip code

Patient Contact

Home Phone

Cell Phone

Email

Any restrictions for contacting you?

Yes

No

Contact Restrictions:

Patient Personal Information

Date of Birth required

Age

SS#

Gender

Male

Female

Other

Marital Status

Single

Married to:

Patient Employer

Employer Name

Occupation

Work Phone

Ext:

Is it okay to call you at work?

Yes

No

Street & Apartment #

City

State

Zip code

How did you hear about us?

(Mark all that apply)

If you were referred by a specific person, may we thank them?

Yes

No

Emergency Contact

(Not in your household)

Name

Relationship to Patient

Home Phone

Work Phone

Other Phone

Areas of Interest:

(Mark all that apply)

I understand that office visit charges are payable on the day service is rendered.

All of the information on this form is accurate to the best of my knowledge.

Your Signature

PLEASE DO NOT HIT SUBMIT UNTIL DR. BLOCH HAS REVIEWED YOUR INFORMATION.

Submitted. Thank you!

CLEAR FORM

Patient Health History

Are you allergic to any one of the following?

Latex

Eggs/Soy products

Drugs (if yes, mention below)

Medical History

Have you ever had...

C.V.S.:

High blood pressure

Heart attack, chest pain, or irregular heart rate

Rheumatic fever, mitral valve prolapse

RESP:

Shortness of breath, hay fever, chronic cough

Lung disease (asthma, emphysema, bronchitis)

C.N.S.:

Migraine headaches, seizures, stroke, depression

GI & LIVER:

Acid reflux, hiatal hernia

Jaundice, hepatitis, or any liver disease

RENAL:

Kidney or bladder disease

ENDO:

Diabetes / Thyroid disorder

HEME:

Anemia, sickle cell, bleeding problems

Blood clots in legs or lungs

OTHER:

Other health / physical related conditions

If you answered yes to any of the above, please expand.

Surgical & Anesthetic History

Surgery requiring anesthesia

If yes, please list type and year.

Complications or ill effects related to anesthesia

Blood relative with H/O anesthetic side effects

If you answered yes to any of the above, please expand.

Other Information

Do you have...

Head, back, or neck pain / joint limitation

Cold, flu, or fever

Do you wear glasses or contacts

Women only...

Last menstrual period

Possibility of pregnancy

Oral contraceptives

Start date:

End date:

If you answered yes to any of the above, please expand.

Social History

Do you use...

Tobacco

If yes, how many packs per day for how many years?

Alcohol

If yes, how often, and how much?

Drugs

If yes, how often and which drug?

Medications

Please write down any medications you currently take. Including dosage and frequency.

All of the information on this form is accurate to the best of my knowledge.

Your Signature

PLEASE DO NOT HIT SUBMIT UNTIL DR. BLOCH HAS REVIEWED YOUR INFORMATION.

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