Patient InformationName First Last What is your reason for visit?*SS/HIC/Patient ID#*Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench 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we thank for referring you?*InsuranceWho is responsible for this account?*Relationship to PatientInsurance CompanyGroup #Is patient covered by additional insurance?*YesNoSubscriber's Name First Last Subscriber's BirthdateSubscriber's SSNRelationship to PatientInsurance CompanyGroup #Phone NumbersCell Phone*Home PhoneIn Case Of Emergency Contact First Last PhoneWork PhoneEmergency Contact Relationship To PatientFamily HistoryFather*AliveDeceasedMother*AliveDeceasedSpouseAliveDeceasedFather's Present Health*Father's Cause of Death*Mother's Present Health*Mother's Cause of Death*Spouses' Present HealthSpouses' Cause of DeathPatient Has Siblings?YesNoPatient Has Children?YesNoBrother(s)*AliveDeceasedNo Brother(s)Sister(s)*AliveDeceasedNo Sister(s)Brother(s) Current Health or Cause of DeathSister(s) Current Health or Cause of DeathChildren*AliveDeceasedNo ChildrenChildren's Ages/Health/Cause of DeathHealth HistoryCheck symptoms you currently have or have had in the past year.Date of Last Physical Examination*GENERAL Chills Depression/Nervousness Dizziness/Fainting Fever Forgetfulness Headache Loss of Sleep Loss of Weight Numbness SweatsMUSCLES/JOINT/BONE Arms Back Feet Hands Hips Legs Neck ShouldersPain, weakness, numbness in:Genito-Urinary Blood in urine Frequent urination Lack of bladder control Painful urinationGASTROINTESTINAL Appetite Poor Bloating Bowel changes Constipation Diarrhea Excessive thirst Gas Hemorrhoids Indigestion Nausea Rectal bleeding Stomach pain Vomiting Vomiting bloodCARDIOVASCULAR Chest pain High/Low blood pressure Irregular/Rapid heart beat Poor circulation Swelling of the ankles Varicose veinsEYE, EAR, NOSE, THROAT Bleeding gums Blurred vision Crossed eyes Difficulty swallowing Double vision Earache/Ear discharge Hay fever Hoarseness Loss of hearing Nosebleeds Persistent Cough Ringing in ears Sinus problems Vision- Flashes/HalosSKIN Bruise easily Hives Itching/Rash Change in moles Scars Sore that won't healMEN ONLY Erection difficulties Lump in testicles Penis discharge Sore on penis OtherWOMEN ONLY Abnormal pap smear Bleeding between periods Breast lump Extreme menstrual pain Hot flashes Nipple discharge Painful intercourse Vaginal discharge OtherDate of Last Menstrual PeriodDate of last Pap SmearHave you had a mammogram?Are you pregnant?Number of ChildrenCheck conditions you have or have had in the past. AIDS Appendicitis Arthritis Asthma Bleeding Disorders Breast lump Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Heart Disease Hepatitis Herpes High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problem Rheumatic Fever Scarlet Fever Stroke Thyroid Problems Tuberculosis Ulcers Venereal DiseaseDescribe Serious Illnesses or OperationsMedications/AllergiesList medications you are currently takingList allergies to medications or substancesPharmacy Name*Phone*Health HabitsCheck if your work exposes you to: Stress Heavy Lifting Hazardous Substances OtherCheck which substances you use: Caffeine Street Drugs Tobacco OtherHow often do you use the selected substance(s)?CAPTCHA