Returning Visit Form
Full Name
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First Name
Last Name
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have a copay or deductible?
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I have a copay
I have a deductible
I am not sure
none
Any change to insurance:
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Check the symptoms that you have experienced in the PAST 6 WEEKS
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Fever/Chills
Unexplained change in weight
Fatigue/Malaise/Generalized weakness
Headaches/Migraines
Dizziness
Sinus Pain/Pressure/Discharge
Vision changes
Wheezing/Chronic Cough
Shortness of breath
Chest pain, pressure or tightness
Swelling of hands/feet/ankles
Nausea/Vomiting
Abdominal pain
Heartburn
Constipation or diarrhea
Stiffness/Pain in joints/muscles
Joint swelling
Bleeding/Easy bruising
Excessive urination
Excessive thirst/hunger
Hot flashes
Painful/Bloody urination
Difficulty urinating/Night-time urination
Urinary incontinence (leakage)
Vaginal discharge or pain
Rash
Anxiety/Panic Attacks
Depression
Insomnia/Problems with Sleep
Thoughts of harming self or others
NONE
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