New Patient Check In for Office Visit

If you have not filled out your New patient Medical History form that was emailed to you, please complete the following check in for your upcoming in office visit with your Provider

New Patient Form – IN OFFICE

First Name and Last Name*
First Last
Best Contact Phone Number*
Email*
Drug Allergies*
Main Concernts/Reason for your visit*
Height: (Ft' In")*
Example: 5’5″ or 5 Ft 5 In
Weight (pounds)*
Medication List: Please List all medications name, Dose and how you are taking the medication.*
example: Synthroid 100 mcg 1 daily OR You may copy and paste a medication list. Please try your best to list dose and directions of your medications
Family History (health problems of your mother, father, siblings, children or grandparents ONLY)*
Example: Diabetes type 1 – Mother, sister
Breast Cancer-maternal grandmother
Previous Health Problems/Hospitalizations/Surgeries/Procedures (Please include exact dates)*
Example: 01/31/2002-Thyroidectomy
Alcohol Use*
- Yes
- No
Number of drinks per day
Example: 01/31/2002-Thyroidectomy
Current Smoker*
- Never Smoker
- Previous Smoker
How many cigarettes Per Day?
Example: 01/31/2002-Thyroidectomy
Exercise – number of days in a week, Duration/Type of exercise:*
Example: 3 days 30 min walking 20 min weight training
Review of System: Please list current Problems/Symptoms you are experiencing now in past 1 month*
Example: Fatigue, Lump in neck, can’t sleep, constipation
Local Pharmacy & Phone # or address / Mail Order Pharmacy*
Example: Walgreens 10010 E Green Street 303-000-0000; Express Scripts