(Never
 do this
 again!)
Patient Information Form
  --- Provided by Intake Solutions, Inc. ---

Instructions: Please use this online form to update your patient information.
  1. Pre-fill the form after entering your Verification Info.
  2. Make changes as needed.
  3. 'Report & Save' your data in a printable report format.
 
Verification Info: (You can pre-fill this form with existing patient data.)
To view patient info: Lname, Initials (Doe, JA): DOB (mmdd):
To add/change info: Mother's Maiden Name: ==>
Last updated:
 
Name (John A. Doe):   DOB: (mm/dd/yyyy)

General Info: (If yes to any item, please explain.)
Under a physician's care now? (name, tel, etc)
Ever hospitalized or had major operation?
Ever had serious head or neck injury?
Taking any medications, pills, or drugs?
Ever taken Phen-Fen or Redux?
Ever taken bisphosphonate meds? (Fosamax, etc)
Do you use controlled substances?
Are you on a special diet?
Do you use tobacco?

Women only:     Pregnant or trying? Nursing? On the pill?
 
Allergic to: Aspirin
Metal
Penicillin
Latex
Codeine
Sulfa Drugs
Acrylic
Local Anesthetics
Any others?:
 
Afflictions:
(Do you have,
or have you had,
any of these?)
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blis
Congenital Heart Dis
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitrial Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumers or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Any others?:
 
Comments:

Disclaimer:   Intake Solutions provides this service for your convenience; we pledge not to sell or release any patient data without explicit patient permission; we will store your data securely. However, Intake Solutions assumes no responsibility if patient data is improperly revealed. It is the responsibility of patients and providers to KEEP THIS DATA SECURE FROM PRYING EYES!!!

© 2010 Intake Solutions Inc. - Princeton, WV   All rights reserved.

97超级碰碰碰碰久久久久_一线完整版在线观看免费_日本三级香港三级人妇三