Patient Information
Date
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Month
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Day
Year
Date
Name
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Address
Age
Birthdate
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Month
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Day
Year
Date
How did you hear about us?
Phone
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Format: (000) 000-0000.
E-mail
example@example.com
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Home Phone
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Format: (000) 000-0000.
Emergency Contact Phone
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Area Code
Phone Number
Current Condition and Medical History
What are your primary reasons for coming in for treatment?
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When did this problem begin?
Have you seen an MD for this problem?
Yes
No
If yes, what was the diagnosis? Please write it here
Please list any and all medications you are currently taking with dosage:
Have you had surgery? If yes, please list here. Include an approximate date:
Do you have allergies? If so, please list them here:
New York State Law requires that we encourage you to go to an MD for any health problems for which you are seeking treatment. Please sign here to acknowledge that you have read and understand this statement, and please feel free to ask us if you have any questions!
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Family History - Diabetes
Yes
No
Family History - Cancer
Yes
No
Family History - High Blood Pressure
Yes
No
Family History - Heart Disease
Yes
No
Family History - Stroke
Yes
No
Family History - Seizures
Yes
No
Family History - Asthma
Yes
No
Family History - AIDS
Yes
No
Family history - Arthritis
Yes
No
Personal or Family History - Other (please specify)
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