Patient Registration Form

First Name

Last Name

Address Line 2

Country

State/Province

Email Address

Date of Birth

Employer

Emergency Contact

Emergency Contact Phone

Reason for visit

Primary Care/Referring Physician (Name & Address)

Prior Medical History

Please list your past medical history

Please list your previous hospitalizations and surgeries

Please list any current medications (Specify doses and frequency)

Please list any current supplements (Specify doses and frequency)

What is your family history of diseases? (mother, father, siblings, children)

Are you allergic to any medications and supplements? If yes, please list the medications and the reactions.

Do you have any food allergies? If yes, please list the foods and the reactions.

If female, are you having menses and are they at regular intervals? Are you pre menopausal, peri menopausal, or post menopausal?

Social History

What is your occupation?

Do you smoke or do you have a history of smoking? If yes, how many packs? how often? and how long?

Do you drink alcohol? If yes, what do you drink, how often, and how many do you drink at one time?

Dietary History

What is your typical breakfast?

What is your typical lunch?

What is your typical dinner?

What are your typical snacks?

Exercise

Do you exercise? If yes, please indicate specific exercises, duration and frequency.

I understand that payment must be rendered at the time of the appointment. By typing my name below, I am indicating that this is a valid substitution for my written signature.

Patient/Responsible Party Name

Prior Medical History

Social History

Dietary History

Exercise

Locations & Contact

East Setauket Office

Brooklyn Office