Patient Registration Form Twitter First Name * Last Name * Street Address * City * Zip/Postal Code * Primary Phone * Primary phone is: * Mobile Home Office Secondary Phone Secondary phone is: Mobile Home Office Address Line 2 Country * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe State/Province * - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Email Address * Date of Birth * Employer Emergency Contact Emergency Contact Phone What sex were you assigned at birth? Male Female Other: What do you identify as? Straight or heterosexual Lesbian, gay or homosexual Bisexual Asexual Don't Know Other: How did you hear about us? Doctor Newspaper/Magazine Internet Search Social media Friend Article Other: 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? Diseases High Blood Pressure High Cholesterol High Triglycerides Diabetes Type 1 Diabetes Type 2 Obesity Heart Disease Stroke Heart Failure Atrial Fibrillation Arrhythmia Autoimmune Disease Crohn’s Disease Inflammatory Bowel Disease Ulcerative Colitis Rheumatoid arthritis Inflammatory arthritis Psoriatic arthritis Multiple Sclerosis - progressive Multiple Sclerosis - relapsing-remitting Lupus Psoriasis Celiac Disease Reflux Disease Eczema Rosacea Peripheral Artery Disease Asthma Cancer Osteoporosis Arthritis/Osteoarthritis Disk Degenerative Disease Hyperthyroid Hypothyroidism Diseases cont. Headache Migraine Irritable Bowel Syndrome Fibromyalgia Depression Anxiety Chronic Kidney Disease Kidney Stones Gallstones Hemorrhoids Parkinson’s Disease Macular Degeneration Glaucoma Cataracts Vascular dementia Dementia Alzheimer’s Dementia Gout Obstructive Sleep Apnea Chronic Fatigue Syndrome Hepatitis Lyme Disease Anemia Overactive Bladder Erectile Dysfuntion Benign prostate hyperplasia Herniated disc Alcoholism/Drug Dependency Seasonal Allergies Chronic Obstructive Pulmonary Disease/Emphysema/Chronic Bronchitis Other Disease(s): Symptoms Shortness of Breath Chest Pain Palpitations Murmur Fatigue Headache Bloating/Gas Unintentional Weight Loss/Weight Gain Diaphoresis (Sweating) Blurry Vision Double Vision Eye Pain Loss of Vision Difficulty sleeping Stress Weakness Difficulty Walking/Immobility Muscle Pain Back Pain Joint Pain/Stiffness Hives Numbness Tingling Difficulty Urinating Increased Frequency of Urinating Urgency of Urinating Feeling of Incomplete Evacuation of Bladder Burning/Pain during Urinating Fever Chills Hair Loss Leg Cramps Hearing Loss Nausea Symptoms Cont. Abdominal Cramps Vomiting Dizziness Sore Throat Cough Wheezing Sputum Sneezing/Congestion Swelling Indigestion/Heartburn Difficulty Swallowing Dry Mouth Constipation Diarrhea Bloody Diarrhea Rectal Bleeding Abdominal Pain Vertigo Increased Thirst Increased Hunger Binge Eating Memory Problems Rash Dry/Peeling Skin Mood Changes Sinus Pain Ringing in Ears Cold or Heat Intolerance Light-headedness/Fainting Easy Bruising or Bleeding Seizures Other Symptom(s): 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. Signature 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 *
