New Patient
Name
First Name
Middle Name
Last Name
Suffix
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
*
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Time Preference
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Preferred Language
*
Ethnicity
*
Race
*
Marital Status
*
Single
Married
Divorced
Widowed
Legally Separated
Emergency Contact
*
Phone Number
*
-
Area Code
Phone Number
Height (inches)
Weight (pounds)
PCP (Primary Care Physician)
*
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select any of the following medical conditions that you currently have or had:
Anxiety
Atrial Fibrillation
Asthma
Benign Prostate Hyperplasia
Bone Marrow Transplant
Breast Cancer
Colon Cancer
Coronary Artery
COPD
Depression
Diabetes
End Stage
GERD
Hearing Loss
Hepatitis
High Colestrol
High Blood Pressure
HIV/AIDs
Hyperthyroidism
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation
Stroke
Seizures
None
Other
Select any of the following surgeries you have had:
Appendix
Bladder (Cystectomy)
Breast: Biopsy
Breast Lumpectomy
Breast Masectomy
Breast Reduction
Breast Augmentation
Colon: Cancer Resection
Colon: Diverticulitis
Colon: Inflammation Bowel Disease
Gallbladder
Heart: Coronary Artery Bypass
Heart: PTCA
Heart Mechanical Valve
Heart: Biological Valve
Heart: Transplant
Joint replacement Knee
Joint replacement Hip
Kidney Biopsy
Kidney Nephrectomy
Kidney Stone Removal
Kidney Transplant
Ovaries: Endometriosis
Ovaries: Ovarian Cyst
Ovaries: Ovarian Cancer
Prostate: Prostate Cancer
Prostate: Prostate Biopsy
Prostate: TURP
Skin: Biopsy
Skin: Basal Cell Carcinoma
Skin: Squamous Cell Carcinoma
Skin: Melanoma
Spleen
Testicles
Uterus: Fibroids
Uterus: Uterine Cancer
Other
None
Select any of the following conditions you currently have or had:
Acne
Actinic Keratosis
Asthma
Basal Cell Carcinoma
Blistering Sunburns
Dry Skin
Eczema
Flaking or itchy scalp
Hay Fever/ Allergies
Melanoma
Melasma
Poison Ivy
Precancerous Moles/ Dysplastic Nevus
Psoriasis
Squamous Cell Carcinoma
Other
None
Do you wear sunscreen?
*
Yes
No
Do you tan in a tanning bed?
*
Yes
No
Do you have family history of Melanoma?
*
Yes
No
Please list any medications you take
Do you pre-medicate with antibiotics before procedures?
*
Yes
No
Do you take blood thinners?
*
Yes
No
List any allergies to medication along with the type of reaction
Social History
Current every day smoker
Current some day smoker
Former smoker
Never Smoker
Do you drink alcohol?
Yes
No
How many times in the past year have you had 5 or more drinks in a day?
Have you received the following:
Shingles vaccine (over 65)
Pneumonia vaccine (over 65)
Age 9-13: A series of 3 HPV (Human Papillomavirus)
Flu Vaccine
Yes
No
Advance Care
Over 65
Do you have a health proxy in the event you are unable to make your own medical decisions?
Yes
No
Designee's Name
First Name
Last Name
Designee's Phone Number
-
Area Code
Phone Number
Do you have a living will?
Which statement reflects your wishes on advanced care recommendations?
Do Not Intubate: I do not wish to have a breathing tube, even if it is necessary to save my life.
Do Not Resuscitate: If my heart were to stop, I do not wish to have chest compressions or an automated external defibrillator to restart my heart, even if it is necessary to save my life
Full Cardiopulmonary Resuscitation: I want full cardiopulmonary resuscitation efforts to be made.
Family History (please indicate member and diagnosis)
How did you hear about us?
Facebook
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Newsletter
Referral
Other
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