Patient Forms

Because Dr. Meger wants you to have as relaxing a visit as possible, we have provided the following forms as a service to you.  By filling them out ahead of your visit, Dr. Meger ensures a stress-free visit. Our staff will assist you with any of your questions about your form on the day of your visit. Thank you in advance for doing your best in answering the questions on your form.

Patient Information

Last Name:
First Name:
Middle Initial:
Address:
City:
State:
Zip:
Date of Birth (Month/Day/Year):
Age:
Social Media has become an important source of information for new and existing patients. Do you use any of the following? Please check all that apply: YelpGoogleFacebookReal Self
Home Phone:
Work Phone:
Cell Phone:
Email:
Patient's Employer:
Employer's Address:
City:
State:
Zip:
Occupation:
Purpose of visit:

Referral

Referral Source:
--- Patient Name:
--- Doctor Name:

Family

Spouse/Legal Guardian:
Relationship to Patient:
Spouse/Guardian Employer:
Phone of Employer:
Employer Street Address:
City:
State:
Zip:

Insurance Information

Primary Insurance:
Address:
City:
State:
Zip:
Name of Insured:
Insured's ID Number:
Group Plan Number:
Secondary Insurance:
Address:
City:
State:
Zip:
Name of Insured:
Insured's ID Number:
Group Plan Number:

Personal History Sheet

Height:
Weight:
Past Medical History
Have you had anything other than the usual childhood diseases? YesNo
Medications (Please use commas when listing your medications):
Drug Allergies:
Previous Surgeries and Approximate Year:
In the past few months, have you had – H & N -
Any eye disease, faulty sight, or eye pain? YesNo
Any ear disease, impaired hearing? YesNo
Any trouble with nose, sinuses, mouth, or throat? YesNo
Hard lumps on tongue, lips or mouth? YesNo
Glaucoma? YesNo
CVR -
Chronic/frequent cough? YesNo
Chest pain or angina pectoris? YesNo
Spitting up of blood? YesNo
Night sweats, chills, fever? YesNo
Shortness of breath? YesNo
Wake up short of breath? YesNo
Palpitation or fluttering of heart? YesNo
Swelling of hands, feet or ankles? YesNo
Rheumatic fever? YesNo
Tuberculosis? YesNo
High or low blood pressure? YesNo
Heart murmur? YesNo
Heart attack? YesNo
GI -
Stomach trouble, ulcer or pain? YesNo
Indigestion, vomiting or nausea? YesNo
Liver or gallbladder disease? YesNo
Any black bowel movements? YesNo
Constipation or diarrhea? YesNo
Recent change in bowel action or stools? YesNo
Cirrhosis of liver? YesNo
Jaundice (yellow)? YesNo
GU -
Kidney disease or stone? YesNo
Bladder disease? YesNo
Albumin, sugar, pus or blood in urine? YesNo
Difficulty controlling urination? YesNo
ENDO -
Abnormal thirst? YesNo
Diabetes? YesNo
Thyroid disease? YesNo
Any diabetes in family? YesNo
List:
HEMO -
Anemia (low blood)? YesNo
Do you bleed or bruise easily? YesNo
Any unusual bleeding after surgery or dental work? YesNo
Any history of Deep Vein Thrombosis or blood clots? YesNo
Any family member a free bleeder? YesNo
If yes, please specify:
NEURO -
Fainting Spells? YesNo
Loss of consciousness? YesNo
Convulsions/epilepsy? YesNo
Paralysis attacks? YesNo
Dizziness? YesNo
Often or severe headaches? YesNo
Migraine Headaches? YesNo
Nervous breakdown? YesNo
PREGNANCIES –
Total number?
How many children born alive?
Are you, or might you be pregnant now? YesNo
Any female trouble now? YesNo
TOBACCO -
Cigarettes? YesNo
Packs per day?