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Demographics *
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Address
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Home Phone
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Work Phone
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Cell Phone
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Date of Birth *
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Must be 9 digits. Currently Entered: 0 digits.
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Employer Address
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Languages Spoken
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Insurance Information (MUST)
Please make a photocopy of FRONT AND BACK of the followings:
1. Your insurance card
2. Your driver's licenses
(No appointment will be made if insurances card and driver information are not received by us)
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Contact in case of Emergency
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Phone number
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Cell Phone
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Health Information
Do you currently suffer from any of the following listed in the left table?
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Others: Have you been in the hospital recently?
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Do you have diabetes?
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If yes, what type of medicine are you using?
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Please answer the following questions:
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Foot Exam Date
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Eye Exam Date
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EKG Date
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Medical History:
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Did you ever have a stroke?
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Are you taking coumadin?
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Do you have cancer?
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If yes, what kind of treatments?
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Did you have heart surgery?
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If yes, please indicate
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Date of Surgery
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Do you have any other surgeries?
If yes, please describe:
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Date of surgery # 1
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Date of surgery # 2
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Pharmacy pone:
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Pharmacy address:
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Allergies:
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Are you allergic to any medication?
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Family Health History
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Tobacco
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Alcohol
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Immunizations
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Type of shot
Do you have any of the following shots?
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Date of last shot (Pneumovax)
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Date of last shot (Influenza)
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Date of last shot (Hepatitis B)
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Date of last shot (Other)
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Radiology
Do you have any radiology done recently?
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Type of labs
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Date (Chest x-ray)
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Date (Other x-ray)
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Date (Mammogram)
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Date (Bone density)
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Date (Colonoscopy)
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Date (Other)
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Social History
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Are you currently employed?
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MEDICATION LIST
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Date Medication # 1
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 2
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 3
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 4
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 5
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 6
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 7
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 8
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 9
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 10
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 11
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 12
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 13
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 14
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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Do you want to add more medication?
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Date Medication # 15
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Medication, Dose, Qty, Frequency
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Medication, Dose, Qty, Frequency
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I agree *
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4, 5, 6, 7 : the 3rd number is?
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