Online Form 2020

First name
Last name
MI
Date of birth

Month Day Year
Date
Parent or legal guardian, If Applicable:
Address
City
State
Zip
Cell #
Home #
Work #
Social Security
Email:
example@example.com
Did your doctor refer you?

Yes No
Marital Status

Single Married Divorced Widowed
Male or Female

Male Female
Primary Care Physician
How did you hear about us?
Emergency Contact Name
Emergency Contact Phone number
Race
Do we have permission to leave a message on your voicemail?

Yes No
Do we have permission to contact you at work?

Yes No
How do you want to get your appointment reminders?

Call Text Email
Primary Insurance
Policy Holder's Name
Policy Holder's date of birth

Month Day Year
Date
ID#
Group #
Relationship to policy holder

Self Spouse Daughter Son
Secondary Insurance
Policy Holder's Name
Policy Holder's date of birth

Month Day Year
Date
ID#
Group #
Relationship to policy holder

Self Spouse Daughter Son
Patient or Guardian Signature

Clear
Date

Month Day Year
Date
Patient Name:
Date:

Month Day Year
Date
Current Weight
Current Height
What is the main reason(s) for your visit today?
Please mark if you currently have or have had any of the following:

Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplant Enlarged Prostate Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes Kidney Disease GERD/ Heartburn Hearing Loss Hepatitis High Blood Pressure HIV/AIDS High Cholesterol Hyperthyroidism Hypothryroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Therapy Seizures Stroke Eczema Melonoma Precancerous moles Psoriasis Skin Cancer
Please list any surgical history ( if applicable) :
If no surgical history mark None:

None
Do you have a family history of Melanoma?

Yes No
If so, who?
Do you have a family history of Skin Cancer?

Yes No
If so, who?
Please list any medications you are currently taking:

None No changes
Medications:
Preferred Pharmacy name and location:
Do we have permission to reconcile your medications with your pharmacy?

Yes No
Please list any allergies to medications:

None
Allergies:
Have you had the flu shot in the past 12 months?

Yes No
Have you had the pneumonia vaccine in the past 12 months?

Yes No
Do you smoke?

Yes No
If yes, how many packs per day?
Do you drink alcoholic beverages?

Yes No
If yes, how many per day?
Do you use IV drugs?

Yes No
Do you have any artificial/replaced joints?

Yes No
Do you require antibiotics before a surgical procedure?

Yes No
Do you have a prosthetic heart valve?

Yes No
Do you have any implantable devices that have been surgically put into your body?

Yes No
Do you have a living will?

Yes No
Do you have a Power of Attorney for healthcare?

Yes No
If so please list name and relationship:
Patient name:
Date:

Month Day Year
Date
Please mark if you are currently experiencing any of the following:

Problems with bleeding Problems with scarring Sore Throat Immunosuppression Chest Pain Fever or Chills Night Sweats Muscke Weakness Neck Stiffness Headaches Bloody Stool Bloody Urine Abdominal Pain Blurry Vision Unintentional Weight Loss Shortness of Breath Wheezing Rash Joint Pain Pregnant or trying to become pregnant Breastfeeding Seizures Cough Problems Bleeding
Are you currently experiencing any pain at this time related to your visit?

Yes No
IF YOU ARE EXPERIENCING PAIN, Please choose your pain level. Your pain on a scale of 0-10, with 0 being none and 10 being the highest level of pain.

0 1 2 3 4 5 6 7 8 9 10
No, I would not like to disclose any of my health information with anyone. Yes, I would like to disclose my health information with the following:
Printed Name of Authorized Person(s) & phone number
Printed Name of Authorized Person(s) & phone number
Patient or Guardian Signature

Clear
Date

Month Day Year
Date
Relationship to patient
Should be Empty: