New Patient Information Form
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Referred by:
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Your Occupation
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Employer:
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Height
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Weight
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Overall Health (select one)
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Other:
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Chief complaint (reason you are here) :
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Previous treatments for this complaint
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Other Complaints or problems
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Current Medications/drugs being taken
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Are you currently under the care of a physician or other health care professional?
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If yes, please give name and date of last visit
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Nutritional supplements you are taking:
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If you smoke, please indicate how much:
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If you drink coffee, please indicate how much:
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if you drink alcohol, please indicate how much:
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Additional information you would like me to know:
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History
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List any major illnesses (with approximate dates):
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Lis any surgery or operations (with approximate dates):
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Marital Status
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Name of Partner
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Describe health of partner
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Number of children (if any)
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Name of Child:
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Age
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Sex
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Any physical conditions or concerns? (If so, please explain)
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Add second child
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Name of Child:
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Age
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Sex
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Any physical conditions or concerns? (If so, please explain)
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Add third child
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Name of Child:
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Age
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Sex
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Any physical conditions or concerns? (If so, please explain)
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Any family history of serious illnesses (select all that apply):
• • •
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Other:
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Any household pets or other animals you or your family members are in close contact with:
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What can I do to make you happier?
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With whom would you like for me to be able to share your health information?
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