Initial Intake / First Office Call Fields with "*" are required. * Date Of Birth: * Full Name: Name Preference: * Address: * City: * State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * Zip: * Home Ph: * Cell Ph: * Work Ph: * Email: * Occupation: What do you do for fun?: Who can we thank for your referral?: In the case of an emergency, call: * Name: * Phone#: * Relationship: * What brings you here today? Medical History (Conditions/illnesses/accidents/injuries) Any Surgeries?: Family History: Mother: Father: Siblings: What is your current form of "Family": Medications: Supplements: Allergies or adverse reactions to anything? Social History: Do you smoke? YesNo If Yes; How much/for how long? Do you drink? YesNo If Yes; How much/for how often? Do you exercise? YesNo If so, what and how often? Describe your sleep: Bowel Habits: Any constipation/diarrhea? How often do you urinate? For Women: If you are still menstruating, describe your cycles: If not, describe your menopause: Pregnancies: how many/# of live births/how was birth and pregnancy for you? What forms of birth control have you used in your life? Are you still sexually active? YesNo Are you happy with your sex life? YesNo Do you get regular pelvic exams? YesNo Are you having safe sex? YesNo Any past or current sexually transmitted diseases? YesNo If so, what was it? For Men: Are you still sexually active? YesNo Are you happy with your sex life? YesNo Are you having safe sex? YesNo Any past or current sexually transmitted diseases? YesNo If so, what was it? Have you had a prostate exam? YesNo Ever had your PSA tested? YesNo Thank you!