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New Patient Form
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Name
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First
Middle
Last
Date of Birth
*
mm/dd/yy
Height/ Weight
*
Address
*
City
Zip/ Postal Code
Cell Number
*
Work/ Home Number
Email
*
Emergency Contact
Pharmacy Phone Number
*
First
Middle
Last
Pharmacy Name
*
Pharmacy Phone Number
*
Pharmacy Address
*
Primary Care Provider
Primary Care Number
*
Primary Care Fax Number
Reason for Visit
*
Past Medical History
*
No medical problems
Depression/ anxiety
Reflux
Diabetes
Asthma
Hypertension
High cholesterol
Obesity
Sleep disorder
Thyroid disease
Autoimmune problem
Mitral Valve Prolapse
PCOS
Anemia
Lupus
Past heart attacks
Pacemaker
Osteoperosis
DVT and/or Pulmonary Embolism
Kidney stones
Kidney disease
Cancer
Arthritis
Memory loss
Other
Drug Allergies
If you don’t have any allergies, no response is necessary
Current Medications
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Surgical History
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Family Medical History
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Diabetes
Heart disease
High blood pressure
Stroke
Cancer
Other
Pregnancy History
Insert total # of pregnancies, any miscarriages/ abortions, C-section deliveries, & vaginal deliveries. Skip if no prior pregnancy.
Currently using any Tobacco products?
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Yes
No
Any consumption of tea, coffee, or sodas?
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Yes
No
Are you sexually active?
*
Yes
No
Do you exercise often?
*
Yes
No
Do you consume alcohol?
*
Yes
No
Maritial Status
Review of Symptoms
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Weight gain
Weight loss
Fever
Chills
Problems sleeping
Daytime sleepiness
Snoring
Depression
Anxiety
Memory problems
Psychosis/ hallucinations
Strokes
Seizures
Fainting spells
Headaches
Dizziness
Chest pain
Shortness of breath
Heart murmur
Palpitations
Foot swelling
Cough
Sodium production
COPD
Heartburn
Change in appetite
Vomiting
Diarrhea
Constipation
Black tarry stool
Change in bowel habits
Rectal bleeding
Vision change
Ear infections
Sinus infections
Trouble swallowing
Impaired hearing
Pain while urinating
Blood in urine
Nighttime urinating
Arthritis
Muscle weakness
Frequent fractures
Osteoporosis
Joint stiffness
Rashes
Jaundice
Cancer
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