First Name *
Last Name *
Your Email *
Address (include city) *
Zip Code *
Patient's Name *
Patient's Gender *
Patient's DOB *
Health Providers *
Do we have permission to release medical information to your health care providers?
Do we have permission to leave you messages on the phone or email? *
TERMS AND CONDITIONS:
Charges billed to the patient/guardian following insurance processing, may accrue interest in accordance with state law. This will not apply if payment arrangements are coordinated within 30 days. You will only receive a patient billing after all other options are exhausted. I understand that by consenting to treatment, I am authorizing the use of information provided to collect payment for medical services in accordance with state laws.
I have read and accept these terms and conditions. *
CHRONIC CONDITIONS: *
ENVIRONMENT / FOOD ALLERGIES:
FAMILY MEDICAL HISTORY:
REVIEW OF SYSTEMS:
The following section is a review of all your systems. Have you been experiencing any of the listed symptoms for each section? If none are applicable please note "none" in each box below each section.
If "Yes" note which ones in the box and describe (e.g. intensity, when, associated with any other symptoms). Please feel free to add any other symptoms you've been experiencing to appropriate category.
CHEST / CARDIOVASCULAR:
HEAD, EARS, EYES, NOSE, THROAT:
GASTROINTESTINAL / HEPATIC:
FEMALE / MALE:
Please be as detailed as possible. Please consider the following elements at a minimum:
1) Where is the symptom?
2) When did it start?
3) How often do you notice it (daily, weekly, montly)?
4) When the symptom is present how long does it last?
5) If you were to rate the intensity and 0 was the lowest and 10 was the most intense what would you rate it today? What would you rate it at its worst?
6) What makes it worse and what makes it better?
7) Is there a time of day that it is worse?
8) How are your "activities of daily living" effected?
LAST OF ALL OTHER ISSUES:
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