Patient Form -

First Name *

Only First Name

Age

Gender

Male
Female
Prefer not to say

Phone (H)

Phone (W)

Phone (cell)

Email *

Occupation

Other Information

Family Physician

Family Physician's Phone

Referred by

Insurance Provider

How did you hear about us?

Name

Please indicate who to notify in case of emergency.

Relationship

Phone (H)

Phone (W)

Phone (cell)

Complaint(s)/Chief Complaint(s)

Please indicate how long you’ve had the condition(s).

Other Complaint(s)

Please indicate how long you’ve had the condition(s).

What kind of treatments have you received?

List any Hospitalizations & Surgeries

Include date and place

List medications being taken

Include dose

Are you allergic to any of the following?

Medicine
Food
Herbs
Others

If yes, please specify.

Do you have a pacemaker?

Yes
No

Do you have severe bleeding disorder?

Yes
No

Are you pregnant?

Yes
No

Do you have Hepatitis A/B/C?

Yes
No

Please check if you have had (in the past three months):

Number of Pregnancies

Number of Abortions

Number of Births

Number of Miscarriages

Time between Menstruation

Duration of Menstruation

First Date of Last Menstruation

Comments

Please tell us of any other problems you would like to discuss.