Name: (Last) (First) (MI) Date: Date of Birth: Age: SS#: Gender: Male Female Height: Weight: Address: City: State: Zip: Home Phone #: Work#: Cell#: Spouse: Emergency Contact: Phone#: Email: Primary Physician: Pharmacy: Referred by: Home Health/Care Facility: Do you want access to your electronic medical record through Patient Portal? Yes No Medication Allergies Medication Allergies No Medication Allergies Are you allergic to LATEX? Yes No Are you allergic to Shellfish/Iodine? Yes No Do you have any metal in your body? Yes No Where Jared K. Manwaring, MD 2001 S. Woodruff, Suite 8 Idaho Falls, ID 83404 (208) 529-0633 Page 1 of 5
Medications Are you currently taking any of the following blood thinners: (Please Circle) Aspirin Motrin Aleve Ibuprofen Celebrex Mobic Heparin Coumadin Warfarin Plavix Pradaxa Xarelto Eliquis Lovenox Other: Please list all medications you take with the dosage and frequency: (Include Vitamins) Medication Dose How Often (If more room is needed, please write on the back.) Past and Present Surgical History Surgery Date Physician (If more room is needed for surgeries, please write on the back.) Jared K. Manwaring, MD 2001 S. Woodruff, Suite 8 Idaho Falls, ID 83404 (208) 529-0633 Page 2 of 5
Medical History Please circle or list any significant medical conditions Heart Disease Hyperthyroidism Diabetes: Type I or Type II Hepatitis B/C Cholesterol/Lipid Disorder Hypothyroidism Insulin Resistant STD s High Blood Pressure Anesthetic Intolerance Prostate Infection HIV/AIDS Heart Attack Bleeding Disorder Enlarged Prostate/BPH Lung Disease Stroke Kidney Failure/Disease Arthritis Depression COPD Kidney Stones Gout Glaucoma Cancer: Family History Indicate the genetic family members affected Bleeding Disorders: Anesthetic Disorders: Heart Disease: Hypertension: Strokes: Diabetes: Prostate Cancer: Cancers: Kidney Disease: Kidney Stones: Other: Family Health History Father Mother Age Living? Deceased? Cause of Death Patient s Children Patient s Brothers Patient s Sisters Jared K. Manwaring, MD 2001 S. Woodruff, Suite 8 Idaho Falls, ID 83404 (208) 529-0633 Page 3 of 5
Social History Circle One: Married Single Divorced Widowed Current smoker: Yes No Packs per day Previous smoker: Yes No Smokeless tobacco: Yes No Do you drink alcohol: Yes No How often? Drank alcohol previously: Yes No Blood transfusion: Yes No Do you drink caffeine: Yes No How many drinks per day? 1 2 3 4+ Recreational drug use: Yes No If yes, please list drugs: Do you consider yourself Hispanic/Latino? Yes No Which category best describes your race? (Check all that apply) White American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander Preferred Language: Jared K. Manwaring, MD 2001 S. Woodruff, Suite 8 Idaho Falls, ID 83404 (208) 529-0633 Page 4 of 5
Insurance Information: Primary Insurance: Insured Name: Policy #: Group #: DOB: SS#: Insurance Address: Insurance Phone #: Parent or Responsible Party Information: (List parent or insured name responsible for bill) Last Name: First Name: Middle Name: Relationship to Patient: Address: City: State: Zip: Home Phone: Cell Phone: DOB: Age: Sex: SS#: Employer: Work Phone: Jared K. Manwaring, MD 2001 S. Woodruff, Suite 8 Idaho Falls, ID 83404 (208) 529-0633 Page 5 of 5