New Patient Packet Please fill in N/A or NONE if not applicable Name(Required) First Last Chart #(Required) Sex(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required)Marital Status(Required) Social Security #(Required) Race(Required) Preferred Language(Required) Ethnicity(Required) Non-Hispanic Hispanic Declined/Unavailable Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Cell Phone(Required)Home PhoneEmergency ContactName & Relationship(Required) Phone(Required)Whom do you authorize to pick up your Prescriptions:(Required) Whom do vou authorize to Speak to a Provider on your behalf:(Required) Whom do you authorize to have Access to your Medical Records:(Required) Insurance:Policy Holder's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Relationship to you(Required) Social Security(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Whom may we thank for referring you?(Required) Please check all that apply to you:Please check all that apply to you: No problems ALLERGIES: Hives/skin rashes Runny nose Food allergies Itchy eyes Hay Fever Sneezing Mold Others CARDIOVASCULAR: Ankle swelling Chest pain Palpitations Hypertension Irregular Heartbeats Painful legs Shortness of breath Varicose veins Others Other (ALLERGIES) Other (CARDIOVASCULAR) GENERAL/CONSTITUTIONAL SYMPTOMS: Appetite change Chills Dizziness Fever Fatigue Headache Hot flashes Nausea Vomiting Sleep Problems Weight Change Others EARS, NOSE, MOUTH, and THROAT: Blisters in mouth Cough Difficulty hearing Difficulty swallowing Sore throat Hoarseness Jaw pain Nasal pain Ringing in ears Sinus problems Ear pain Others Other (GENERAL/CONSTITUTIONAL SYMPTOMS) Other (EARS, NOSE, MOUTH, and THROAT) ENDOCRINE: Cold intolerance Dry skin Flushing Hair loss Heat intolerance Diabetes Menopause Sluggish Height loss Thirst Others EYES: Blurred vision Dry eyes Eye discharge Loss of vision Eye pain Photosensitivity Visual changes Watering eyes Others Other (ENDOCRINE) Other (EYES) GASTROINTESTINAL: Abdominal pain Bloating Blood in stool Constipation Rectal Bleeding Diarrhea Gas Hemorrhoids Indigestion IBS Others GENITOURINARY: Abnormal PAP Blood in urine Overactive bladder Decreased libido Urinary problems Vaginal discharge Painful testicles Erectile dysfunction Menstrualpain Others Other (GASTROINTESTINAL) Other (GENITOURINARY) Date of last PAP MM slash DD slash YYYY Date of last period MM slash DD slash YYYY HEMATOLOOGIC/LYMPHATIC: Bleeding problems Blood clotting problems Swollen lymph nodes Bruise easily Anemia Others PSYCHIATRIC: Mood changes Anxious Suicidal thoughts Panic attacks Depression Others Other (HEMATOLOOGIC/LYMPHATIC) Other (PSYCHIATRIC) INTEGUMENTARY (SKIN): Acne Blisters Boils Change in mole Breast lump Non-healing wound Eczema Dry skin Others MUSCULOSKELETAL: Arthritis Back pain Joint pain Neck pain Leg pain Muscle pain MVA injury Sciatica Others Other (INTEGUMENTARY) Other (MUSCULOSKELETAL) NEUROLOGICAL: Migraine Confusion Vertigo Seizures Difficulty concentrating/speaking Syncope Tremors Paralysis Others RESPIRATORY: Asthma Breathing difficulty Pneumonia Coughing up sputum Dyspnea Sleep apnea Snoring Wheezing Others Other (NEUROLOGICAL) Other (RESPIRATORY) PERSONAL MEDICAL HISTORY (Check all that apply)(Required)DISEASE/CONDITIONCurrentPastComments Add RemoveMEDICATIONS (Include over the counter)(Required)MEDICATIONSDoseTimes Per Day Add RemovePharmacy Address(Required) Pharmacy Name Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pharmacy Phone(Required)Pharmacy Fax(Required)ALLERGIES (Include food/environmental allergies)ALLERGYReaction Add RemoveSERIOUS INJURY/SURGERIES/HOSPITALIZATIONS (Include childbirth)TYPEDateFacility Add RemoveSPECIALISTS (Eye Doctor, Cardiology, Gastroenterology, Ob/Gyn, etc)SPECIALISTNameLast Visit/Frequency of Visits Add RemoveHEALTH MAINTENANCE/VACCINATIONSLast Physical Exam/WellnessDate:Facility:Abnormal Result? Add RemoveCholesterol ScreenDate:Facility:Abnormal Result? Add RemoveColonoscopyDate:Facility:Abnormal Result? Add RemoveMammogramDate:Facility:Abnormal Result? Add RemovePap SmearDate:Facility:Abnormal Result? Add RemoveBone DensityDate:Facility:Abnormal Result? Add RemoveLast Tetanus BoosterDate:COVID Vaccine (s)Date (s): Add RemoveLast Flu VaccineDate:Pneumonia Vaccine (s)Date (s): Add RemoveZoster Vaccine(Shingles)Date:HPV Vaccine (s)Date (s): Add RemoveFAMILY MEDICAL HISTORY MGM= maternal grandmother, MGF= maternal grandfather, PGM= paternal grandmother, PGF= paternal grandfatherDeceased? At what age?MotherFatherBrother/sSister/sMGMMGFPGMPGFAlcoholism/ Drug AbuseMotherFatherBrother/sSister/sMGMMGFPGMPGFAsthmaMotherFatherBrother/sSister/sMGMMGFPGMPGFCancer (specify)MotherFatherBrother/sSister/sMGMMGFPGMPGFDepression / Anxiety / BipolarMotherFatherBrother/sSister/sMGMMGFPGMPGFType 2 DiabetesMotherFatherBrother/sSister/sMGMMGFPGMPGFEmphysema (COPD)MotherFatherBrother/sSister/sMGMMGFPGMPGFHeart DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFHypertensionMotherFatherBrother/sSister/sMGMMGFPGMPGFHigh CholesterolMotherFatherBrother/sSister/sMGMMGFPGMPGFThyroid DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFKidney DiseaseMotherFatherBrother/sSister/sMGMMGFPGMPGFMigraine HeadachesMotherFatherBrother/sSister/sMGMMGFPGMPGFStrokeMotherFatherBrother/sSister/sMGMMGFPGMPGFOtherMotherFatherBrother/sSister/sMGMMGFPGMPGF Add RemoveSOCIAL HISTORY1. How much exercise do you get weekly?(Required) 2. Have you ever smoked tobacco?(Required) Yes No a. Current smokers:(Required) Yes No How long have you smoked?(Required) How much currently smoking?(Required) b. Past smokers(Required) Yes No Quit date(Required) How long did you smoke?(Required) How much did you smoke?(Required) 3. Do you have any secondhand smoke exposure?(Required) 4. Do you use any drugs? (Please specify)(Required) 5. Do you drink alcohol?(Required) Yes No a. How much do you drink weekly?(Required) b. What do you typically drink?(Required) 6. What is your occupation (retired, disabled, unemployed)(Required) 7. If not USA, what is your country of origin?(Required) 8. If not English, what is your preferred language?(Required) 9. Check if your work exposes you to the following:(Required) Stress Hazardous Substances Heavy lifting Other Other. (work exposes) 10. Do you have trouble functioning in everyday tasks due to anxiety, memory loss, location or other reasons?(Required) 11. Do you have a lack of social support at home?(Required) 12. Do you feel your over all health is adversely affected by here you live or work?(Required) 13. Are you unable to afford care or prescriptions?(Required) 14. Are you unable to obtain proper nutrition?(Required) 15. Is your home/workplace unsafe?(Required) AUTHORIZATION TO OBTAIN HEALTHCARE INFORMATIONPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Records Being Requested From:(Required) Facility or Provider Name: Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Records Being Requested By: Facility or Provider Name: Address City North CarolinaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Being Requested(Required) Office Visit Notes Laboratory Test Results Radiology Report (includes x-ray, MRI, CT, bone destiny scan, etc.) Entire Record Record related to the following conditions or events: Records within a specific time frame (examples: 2017 – present, most recent, or last 3 visits:) Conditions(Required) Timeframes(Required) Consent(Required) By checking this,I understand that I am authorizing the use and/or disclosure of the patient’s protected health information as described in this document.