First Name

Middle Initial

Last Name

Address

City State Zip

Phone Cell Phone

Work Phone

CDL#

Date of Birth:
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Marital Status:
Single
Married
Divorced
Widowed
Separated

Are you under a physician's care now?
Yes
No
If yes, please explain:

Have you ever been hospitalized or had a major operations?
Yes
No
If yes, please explain:

Have you ever had a serious head or neck injury?
Yes
No
If yes, please explain:

Are you taking any medications, pills, or drugs?
Yes
No
If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?
Yes
No

Are you on a Special diet?
Yes
No

Do you use tobacco?
Yes
No

Do you use controlled substances?
Yes
No

Women, are you :

Pregnant/Trying to get pregnant? Yes No

Taking oral Contraceptives? Yes No

Nursing? Yes No

Are you allergic to any of the following?

Aspirin Penicillin

Codeine Acrylic

Metal Latex

Sulfa Drugs Iodine

Local Anesthetics Other

If yes, please explain:

Do you have, or have you had, any of the following?

Acid Reflux AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions

Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Fibromyalgia Frequent Cough Frequent Diarrhea Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease

Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis/Osteopenia Pain in Jaw Joints Parathyroid Disease Psychiatric Care

Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice

Have you ever had any serious illness not listed above?
Yes
No
If yes, please explain:

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