Regenerative Medical Initial Form

1
Personal* This field is required.
First Name
Last Name
Date of Birth
Select One
Select One
Male
Female
Sex
Race/Ethnicity
Phone Number
Email Address
2
Family
Please Select
Please Select
Single
Married
Divorced
Widowed
Marital Status
Spouse's Name
Child's Name & Age
Child's Name & Age
Child's Name & Age
Child's Name & Age
Emergency Contact's Name
Emergency Contact's Phone Number
3
Employment* This field is required.
Occupation
Employer
Address
City
State
Zip
4
Address
Street Address
Address Line 2
City
State
Zip Code
5
Do you have health insurance?* This field is required.If you have any health insurance at all, even if you don't believe your insurance will cover our services, please select yes so that we can verify it.
YESNO
6
Insurance
Insurance Carrier
Policy Number
Please Select
Please Select
Self
Spouse
Parent
Who carries this policy?
Insured's First Name
Insured's Middle Name
Insured's Last Name
Insured's Birth Date
Insured's Employer
7
How did you hear about us?* This field is required.
Referral from Friend/Family
Suburban Essex
Other Magazine/Newspaper
Instagram
Facebook
Internet
Gym/Health Club
School Event
Other
8
Who referred you?Please enter the name of the person who referred you to us.
9
Other Referral SourcePlease describe how you first heard about us.
10
MusculoskeletalPlease indicate any condition that you've previously had or currently have.
Neck Pain
Shoulder Pain
Elbow Pain
Arm Pain
Wrist/Hand Pain
Back Pain
Hip Pain
Knee Pain
Leg Pain
Ankle/Foot Pain
Arthritis
Osteoporosis
11
Neurological
Headaches
Anxiety
Depression
Dizziness
Pins & Needles
Numbness
Tingling
Shingles
Epilepsy
Multiple Sclerosis
12
Cardiovascular
High Blood Pressure
Low Blood Pressure
High Cholesterol
Poor Circulation
Excessive Burning
Heart Disease
Stroke
Arteriosclerosis
Angina
13
Digestive
Anorexia
Bulimia
Ulcer
Food Sensitives
Heartburn
Constipation
Diarrhea
Hepatitis
14
Respiratory
Asthma
Apnea
Emphysema
Hay Fever
Shortness of Breath
Pneumonia
Allergies
15
Skin
Skin Cancer
Psoriasis
Eczema
Rash
16
Constitutional
Fainting
Fatigue
Weakness
Poor Appetite
Low Libido
Sudden Weight Gain or Loss
17
Genitourinary
Kidney Stones
Infertility
Bedwetting
Prostate Issues
Erectile Dysfunction
PMS Symptoms
STDs
18
Endocrine
Thyroid Issues
Goiter
Immune Disorders
Hypoglycemia
Frequent Infection
Swollen Glands
Low Energy
Diabetes
19
Sensory
Blurred Vision
Glaucoma
Ringing in Ears
Hearing Loss
Loss of Taste
Loss of Smell
Chronic Ear Infection
20
IllnessPlease indicate any illnesses or other conditions you have had or currently have.
Gout
Cancer
Polio
Chicken Pox
Mumps
Measles
Rheumatic Fever
Scarlet Fever
Typhoid Fever
Tuberculosis
AIDS
HIV Positive
Alcoholism
Other
21
SurgeriesPlease indicate any surgeries or operations you have had.
Cancer
Neck
Back
Shoulder
Hip
Hip Replacement
Knee (Arthroscopic)
Knee Replacement
Heart
Pacemaker
Eye
Cosmetic
Vasectomy
Hysterectomy
Appendix Removal
Tonsillectomy
Bypass
Other
22
TreatmentsPlease indicate any treatments that you've had or are receiving.
Acupuncture
Antibiotics
Birth Control Pills
Blood Transfusions
Chemotherapy
Chiropractic Care
Dialysis
Homeopathy
Hormone Replacement
Inhaler
Massage Therapy
Physical Therapy
Vitamins
23
MedicationPlease list all medications that you currently take.
Huge
Large
Normal
Small
Ok
Ok
24
HabitsHow Often?
Alcohol
Tobacco
Drugs
Pain Relievers
Coffee
Soft Drinks
Water
Exercise
25
GoalsWhat would be the most significant thing that you could do to improve your health?
Huge
Large
Normal
Small
Ok
Ok
26
Goals In addition to the main reason for your visit today, what additional health goals do you have?
Huge
Large
Normal
Small
Ok
Ok
27
Consent* This field is required.Agree to the statement by checking the box on the left side.
I request and consent to the performance of medical procedures, including, but not limited to, various modes of intravenous drips, injections, blood work, testing, and cosmetic treatments and procedures, on me by the doctors and/or clinical staff of NJ Health Hub.
28
Risks to Treatment* This field is required.Agree to the statement by checking the box on the left side.
I understand and am informed that,as in the practice of medicine, there are some risks to treatment. I do not expect the doctor and/or clinical staff members to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor and/or clinical staff members to exercise judgment during the course of the procedure which the doctor and/or clinical staff members feel at the time, based upon the facts then known, is in my best interests.
29
Insurance and Payment* This field is required.Agree to the statement by checking the box on the left side.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services that I receive.
30
Truthful Information* This field is required.Agree to the statement by checking the box on the left side.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented to the presence, severity, or cause of my health concerns.
31
Signature* This field is required.Whereas I have read and understand the foregoing, of my own free will and volition I choose to sign this acknowledgement, undergo treatment(s), and waive any claims against NJ Health Hub and its related clinical staff, employees, advisors, directors, and owners. By signing on the line below, I understand and agree that this electronic signature is the legal equivalent of my pen and paper signature.
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