Form
Patient Information Form
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Age
*
Sex
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Martial Status:
*
Married
Single
Divorced
Widowed
Separated
Occupation of Patient
Employer/Company Name
Spouse's Name
Spouse's Employer
Do You Drink?
*
Yes
No
Do you Smoke?
*
Yes
No
Height
*
Weight
*
In Case Of An Emergency: Whom Should We Contact?
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Health History
Check symptoms you currently have or have had in the past year.
General
Chills
Depression
Dizziness
Fainting
Fever
Forgetfullness
Headache
Loss of Sleep
Loss of Weight
Nervousness
Sweats
Eyes
Crossed Eyes
Double Vision
Vision - Flashes
Vision - Halos
Blurred Vision
Ears/Nose/Throat
Earache
Ear Discharge
Ringing in Ears
Loss of Hearing
Hay Fever
Sinus Problem
Nose Bleeds
Bleeding Gums
Hoarseness
Difficulty Swallowing
Persistent Cough
Respiratory
Shortness of Breath
Couch
Congestion
Distress
Sputum
Endocrine
Weight Gain
Weight Loss
Hoarseness
Heat Intolerance
Cold Intolerance
Breast Changes
Hair Changes
Extreme Thirst
Genito-urin
Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination
Gastrointestinal
Poor Appetite
Bloating
Bowel Changes
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Gas
Hemorrhoids
Indigestion
Nausea
Rectal Bleeding
Stomach Bleeding
Stomach Pain
Vomiting No Blood
Vomiting Bleeding
Cardiovascular
Chest Pain
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Poor Circulation
Rapid Heart Beat
Swelling of Ankles
Varicose Veins
Muscle/Joint/Bone
Arms
Hips
Back
Legs
Feet
Neck
Hands
Shoulders
Psychiatric
Hyperventilation
Insecurity
Depression
Trouble Sleeping
Irritable
Anxiousness
Undecidedness
Timid
Hallucinations
Loss of Memory
Alcoholism
Drug Addiction
Drug Dependency
Extreme Worry
Sexual Problems
Suicidal Thoughts
Neurological
Seizures
Vertigo
Dizziness
Hand Trembling
Loss of Sensations
Loss of Facial Expression
Weak Grip
Paralysis
Difficulty of Speech
Tingling
Loss of Memory
Numbness
Incoordination
Integumentary
Bruise Easy
Hives
Change in Moles
Sores that won't heal
Itching
Unusual Swelling
Sores/Ulcers
Rash
Scars
Conditions
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Asthma
Bleeding Disordered
Breast Lumps
Bronchitis
Breath Shortness
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempt
Thyroid Fever
Ulcers
Vaginal Infections
Venereal Disease
Women Only
Abnormal Pap Smear
Bleeding Between Periods
Breast Lumps
Extreme Menstrual Pain
Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge
Other
Date of Last Menstrual Period
Date of Last Pap Smear
Have you had a mammogram?
Are you pregnant?
Number of Children
Men Only
Breast Lumps
Erection Difficulties
Lump in Testicles
Penis Discharge
Sore on Penis
Other
Date of Last Menstrual Period
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Last Pap Smear
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Children
Medications - List Medications you are currently taking and dosages
*
Allergies to medications or substances
*
Wellness/Weight Loss Exam Form
How much weight would you like to lose? *
How did you hear about us?
History: (major surgeries, hospital stays, etc.)
Any Active Cancer?
*
Yes
No
Any Active Gall Bladder Disease?
*
Yes
No
Are You Pregnant?
*
Yes
No
Are You Breastfeeding?
*
Yes
No
Release of Information
I hereby authorize SPINALAID to use, disclose, and/or release my protected health information to my insurance carriers) or other medical facilities to assist in my care, treatment, or payment of my medical claim. This information may be acquired in the course of my medical examination and/or treatment and may include drug use, alcoholism, and HIV positive test results.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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