Información clínica

Patient Name(Obligatorio)

Nombre Apellidos

Date of Birth(Obligatorio)

Gender(Obligatorio)

Height(Obligatorio)

Weight(Obligatorio)

Email(Obligatorio)

Patient Phone(Obligatorio)

Emergency Contact Name(Obligatorio)

Nombre Apellidos

Emergency Contact Phone Number(Obligatorio)

Address(Obligatorio)

Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal País

Please state the reason for your visit:(Obligatorio)

Upload Photo Identification

Tipos de archivos aceptados: jpg, gif, png, pdf, tiff, doc, docx, , maxfilesize:8mb, Tamaño máximo de archivo: 128 MB.

Injury Details

Is your complaint due to an injury?(Obligatorio)

Allergies: Please list all medication, environmental, metal or jewelry allergies

Do you have any allergies?(Obligatorio)

Medications: Please list ALL current medications

Are you currently taking any medications?(Obligatorio)

Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeries

Are you currently taking any medications?(Obligatorio)

Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeries

Family Member

Mother Alive or Deceased?

Mother Medical Illnesses

Family Member

Father Alive or Deceased?

Father Medical Illnesses

Family Member

Sibling(s) Alive or Deceased?

Sibling(s) Medical Illnesses

Habit Details

Current Cigarette Smoker?(Obligatorio)

Past Cigarette Smoker?(Obligatorio)

Vape User?(Obligatorio)

Nicotine User?(Obligatorio)

Herbal User?(Obligatorio)

Do you drink alcohol?(Obligatorio)

Have you been diagnosed with or treated for the following problems?

Acid Reflux?(Obligatorio)

Kidney Stones?(Obligatorio)

Pulmonary Embolous?(Obligatorio)

Emphysema?(Obligatorio)

Stomach Ulcer?(Obligatorio)

Coronary Artery Disease?(Obligatorio)

Diabetic?(Obligatorio)

Cancer?(Obligatorio)

Sleep Apnea?(Obligatorio)

Dialysis?(Obligatorio)

Uses CPAP?(Obligatorio)

COPD?(Obligatorio)

High Blood Pressure?(Obligatorio)

HIV?(Obligatorio)

Blood clot in legs or arms?(Obligatorio)

Congestive Heart Failure?(Obligatorio)

Hepatitis?(Obligatorio)

Tuberculosis?(Obligatorio)

Asthma?(Obligatorio)

Diabetic Neuropathy?(Obligatorio)

Chronic Kidney Disease?(Obligatorio)

Heart Attack?(Obligatorio)

Thyroid Disease?(Obligatorio)

High Cholesterol?(Obligatorio)

Do you take anticoagulants?(Obligatorio)

Reason

Duration of care:

Please list any other health conditions, not listed above:

Patient Signature(Obligatorio)

Date(Obligatorio)

Información clínica

Injury Details

Allergies: Please list all medication, environmental, metal or jewelry allergies

Medications: Please list ALL current medications

Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeries

Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeries

Habit Details

Have you been diagnosed with or treated for the following problems?

Charlotte

High Point

Wilmington

Raleigh

Rock Hill