82 Ballards Corner Road
PO BOX 592
Hinesburg, VT 05461
Phone: 802-482-3155

Patient Information Form

    MaleFemale
    YesNo
    MarriedNot Married
    YesNo
    ExcellentGoodFairPoor
    ExcellentGoodFairPoor
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo


    High Blood PressureLow Blood PressureHeart MurmurMitral Valve ProlapseArtificial Heart ValveCongenital Heart LesionHeart SurgeryHemophiliaPacemakerBlood DiseaseStrokeHIVHeart TroubleChest PainAnemiaThyroid DiseaseHepatitisKidney DiseaseUlcersLiver DiseaseDiabetesHypoglycemicGlaucomaPsychiatric CareAllergiesEmphysemaSinus TroubleShortness of BreathCancerLung DiseaseAsthmaRheumatic FeverChemo/RadiationRecent Weight LossEpilepsyFaintingArtificial Joints/HipsAlzheimer'sArthritis/GoutSwelling/Feet/Ankles/Hands

    I understand that my name will act as my signature.
    I allow Dr. Stephens permission to discuss my conditions with my physician and to request medical information from him or her when necessary
    [recaptcha]