New Patient Medical Information

Patient Name:

DOB:

Reason for visit:

Preferred Pharmacy

Location

Height

Weight

Food Allergies

Drug allergies

Medications you are currently taking (include any over the counter medications):

Are you on blood thinners?

Yes No

Have you received the flu shot?

Yes No

If yes, Date?

Have you received the Covid Vaccine?

Yes No

If yes, Date?

Has anyone in your family had/have the following conditions:

Who?

What?

Who?

What?

Who?

Type?

Have you had any of the following?

Left Right Joint:

Approx Date:

Left Right Joint:

Approx Date:

Location

Approx Date:

Type

Last A1c

Last Blood Sugar

Circle any of the following conditions you currently have or have had in the past

Others

If Heart Problems, Please specify

If Skin Condition? Please specify