NEW PATIENT INFORMATION FORM

The form is for NEW patients only!  If you are an existing client of The Doctors Desk who is seeking a new consultation, please go to Existing Patient Consolation to access the appropriate form.

CONTACT INFORMATION

Today’s Date: ________________ (mm/dd/yr)                            Driver’s License #:__________________ State: ____

                                                                                                   Date of Birth: __________________ (mm/dd/yr) Age: ____

Name :____________________( Last) ______________________ (Maiden) _________ (MI) ____________ (First)

Email Address: _______________________ Home Phone: ______________ Alternate Phone: _________________

Home Address: ____________________ (street) ________ (Apt. #) ________________________ (City, State, Zip)

Our doctors are on call Monday – Friday.  What is the best day & time for your consolation?  We will do our best to accommodate you!:

_________________ 1^st Choice

________________ 2^nd Choice

_________________ 3^rd Choice

We will contact you with your consultation information via email.  If you do not have an email address please select a method of contact:                                                      (Home Phone               Alternate Phone) _________________

MEDICAL INFORMATION

Sex:  Male     Female                               Height: _______ Weight: ________

Reason for consultation: _________________________________________________________________________

When did the condition begin? ____________________________________________________________________

Is the condition getting worse?      Yes       No      Constant           Comes & Goes

Is the condition interfering with your:       Work        Sleep      Daily Routine

Have you had this medical condition in the past?     Yes     No      If yes, please explain: __________________________

Have you been treated by a medical physician for this condition?     Yes     No

If yes, please provide your physician’s information:    Doctor’s Name: _______________________________________

                                                                                                  Address: ___________________________________________

                                                                                                   Phone #: ___________________________________________

Are you seeking a specific medication?   Yes   No    If yes, please indicate name of medication(s):___________________

Are you currently taking this medication?     Yes     No

Have you taken this medication in the past?       Yes    No   If yes, when? _____________________________________

What medications are you currently taking? __________________________________________________________

Date of last Physical: ____________________ (mm/dd/yr)

Allergies (ie: medications, food, animals, pollen, etc.): ___________________________________________________

Do you smoke?     Yes    No    If yes, how often and how much? ___________________________________________

Do you drink alcohol?    Yes   No    If yes, how often and how much? _______________________________________

Have you ever had any of the following diseases / medical conditions?

____Heart Attack/Stroke         ____Heart Surgery/Pacemaker        ____Heart Murmur                           ____Congenital Heart Disease

____Mitral Valve Prolapse      ____Artificial Valves                       ____Alcohol/Drug Abuse                  ____Venereal Disease

____Hepatitis                          ____HIV/AIDS                                ____Shingles                                     ____Cancer

____Frequent Neck Pain          ____Emphysema/Glacoma              ____Anemia                                     ____High/Low Blood Pressure

____Psychiatric Problems       ____Rhematic Fever                        ____Severe/Frequent Headaches        ____Kidney Problems

____Ulcers/Colitis                   ____Fainting/Seizures/Epilepsy        ____Sinus Problems                           ____Asthma

____Diabetes/Tuberculosis       ____Difficulty Breathing                 ____Chemotherapy                          ____Lower Back Problems

____Artificial Bones/Joints      ____Arthritis           Do you know of any family medical conditions of illnesses?  Yes     No

If yes, please explain: _____________________________________________________________________________________________

Are you taking birth control?  Yes   No

Are you pregnant?       Yes      No         If yes, for how long? _____________       Are you nursing?    Yes      No

REQUEST FOR MEDICAL RECORDS

If requested by the doctor, I, _______________________ authorize Dr. _____________________ to disclose my medical history and medical treatment information to The Doctors Desk.

I understand that the parties receiving these records may not further disclose the medical information unless otherwise authorized to do so by me or unless such disclosure is specifically required or permitted by low.

Signature: _______________________________ Date: _________________

Please feel free to discuss any questions or concerns regarding our services with us.  I understand the above information and guarantee that to the best of my knowledge, all information I have provide is accurate.  I also understand it is my responsibility to inform The Doctors Desk to any changes in my medical status.

Signature: _______________________________ Date: __________________