Patient Information Form

Form
Patient Information Form
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Current Age*
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / 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:*

MarriedSingleDivorcedWidowedSeparated
Occupation of Patient
Employer/Company Name
Spouse's Name
Spouse's Employer
Do You Drink?*

YesNo
Do you Smoke?*

YesNo
Height*
Weight*
In Case Of An Emergency: Whom Should We Contact?
Name

First NameLast 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

ChillsDepressionDizzinessFaintingFeverForgetfullnessHeadacheLoss of SleepLoss of WeightNervousnessSweats
Eyes

Crossed EyesDouble VisionVision - FlashesVision - HalosBlurred Vision
Ears/Nose/Throat

EaracheEar DischargeRinging in EarsLoss of HearingHay FeverSinus ProblemNose BleedsBleeding GumsHoarsenessDifficulty SwallowingPersistent Cough
Respiratory

Shortness of BreathCouchCongestionDistressSputum
Endocrine

Weight GainWeight LossHoarsenessHeat IntoleranceCold IntoleranceBreast ChangesHair ChangesExtreme Thirst
Genito-urin

Blood in UrineFrequent UrinationLack of Bladder ControlPainful Urination
Gastrointestinal

Poor AppetiteBloatingBowel ChangesConstipationDiarrheaExcessive HungerExcessive ThirstGasHemorrhoidsIndigestionNauseaRectal BleedingStomach BleedingStomach PainVomiting No BloodVomiting Bleeding
Cardiovascular

Chest PainHigh Blood PressureIrregular Heart BeatLow Blood PressurePoor CirculationRapid Heart BeatSwelling of AnklesVaricose Veins
Muscle/Joint/Bone

ArmsHipsBackLegsFeetNeckHandsShoulders
Psychiatric

HyperventilationInsecurityDepressionTrouble SleepingIrritableAnxiousnessUndecidednessTimidHallucinationsLoss of MemoryAlcoholismDrug AddictionDrug DependencyExtreme WorrySexual ProblemsSuicidal Thoughts
Neurological

SeizuresVertigoDizzinessHand TremblingLoss of SensationsLoss of Facial ExpressionWeak GripParalysisDifficulty of SpeechTinglingLoss of MemoryNumbnessIncoordination
Integumentary

Bruise EasyHivesChange in MolesSores that won't healItchingUnusual SwellingSores/UlcersRashScars
Conditions

AIDSAlcoholismAnemiaAnorexiaAppendicitisAsthmaBleeding DisorderedBreast LumpsBronchitisBreath ShortnessBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPneumoniaPolioProstate ProblemPsychiatric CareRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid FeverUlcersVaginal InfectionsVenereal Disease
Women Only

Abnormal Pap SmearBleeding Between PeriodsBreast LumpsExtreme Menstrual PainHot FlashesNipple DischargePainful IntercourseVaginal DischargeOtherDate of Last Menstrual PeriodDate of Last Pap SmearHave you had a mammogram?Are you pregnant?Number of Children
Men Only

Breast LumpsErection DifficultiesLump in TesticlesPenis DischargeSore on PenisOther
Date of Last Menstrual Period

MonthDayYear
Date
Date of Last Pap Smear

MonthDayYear
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?*

YesNo
Any Active Gall Bladder Disease?*

YesNo
Are You Pregnant?*

YesNo
Are You Breastfeeding?*

YesNo
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

MonthDayYear
Date
Should be Empty:

Form

Patient Information Form

In Case Of An Emergency: Whom Should We Contact?

Health History

Wellness/Weight Loss Exam Form

Release of Information