Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *SSN: *If no SSN please write 000000000Marital Status *SingleMarriedDivorceWidowedLegally SeparatedSex *FemaleMaleTransgenderI rather not answerRace *American Indian or Alaska NativeAsianBlack or African AmericanCaucasianMultiracialOther RaceDecline to SpecifyEthnicity *HispanicNon-hispanicPreferred Language *How do you wish to be contacted *EmailPhoneMailing Address *Mobile Phone: *Home Phone: *It could be the same as mobile numberEmail *Birthplace *Patient's OccupationPatient's EmployerEmergency Contact Name *Emergency Contact Phone Number *Emergency Contact Relationship *Are you the Primary Policy Holder (Health Insurance)? *YESNOIf NO, please enter Primary Policy Holder's name:Primary Policy Holder's Date of BirthPrimary Policy Holder's SSNMain Reason for Your Visit Today *Primary Care Physician's NamePharmacy's Name *Pharmacy's Phone NumberPharmacy's Zip Code *Personal Medical History *CataractsHypertension (HTN)COPD/EmphysemaAllergic rhinitisAcid reflux (GERD)Heart diseaseCirrhosisHeartburnHepatitisAsthmaHerniaKidney diseaseSTDsDermatitisPsoriasisEpilepsyStrokeBipolarDepressionDiabetes Type 1 (Type I DM)Diabetes Type 2 (Type II DM)HypothyroidismAnemiaCancerHIVTuberculosis exposure (latent TB)OtherNONEPersonal Medical History not Included AbovePast Medical Personal History (Rheumatologic)Unknown Type of ArthritisOsteoarthritisGoutChildhood ArthritisPsoriatic ArthritisLupus or Systemic Lupus ErythematosusRheumatoid ArthritisAnkylosing SpondylitisOsteoporosisFibromyalgiaOsteoporosisOtherMajor Surgeries and Hospitalizations (Reason, Date and Name of the Hospital) *Example: Cesarean Section 2018 Palomar Hospital Escondidio. If none, please write "None".Past Medical FAMILY History (Rheumatologic) *Unknown Type of ArthritisOsteoarthritisGoutChildhood ArthritisPsoriatic ArthritisLupus or Systemic Lupus ErythematosusRheumatoid ArthritisAnkylosing SpondylitisOsteoporosisFibromyalgiaOsteoporosisOtherNONE*if there is Family Medical History: please state relationship to patient, age (if deceased), and condition *If none, please write '"None". Example: Mother, died at age 80, rheumatoid arthrisis and osteoporosisUse of Tobacco *Current every day smoker Current some day smoker Former smokerHeavy tobacco smoker Light tobacco smoker Never smoker Smoker, current status unknown Unknown if ever smoked Do You Drink Alcohol? *Do not drinkDrink dailyFrequently drinkHistory of alcoholismOccasional drinkUse of Illicit Drugs *Intravenous Drug User (IVDU)Illicit Drug UseNo Illicit Drug UseHave you ever broken a bone as an adult? (Please list which bone and your age it occured)Have you ever had a blood transfusion? *YESNOHave you ever been tested for TB? *YES (negative result)YES (positive result)NOHave you ever been tested for Hepatitis B/Hepatitis C? *YesNoThird ChoiceFemale patient: Are you pregnant?YESNONot SureFemale patient: Planning to become pregnant?YESNONot SureFemale patient: Have You Ever Been Pregnant?YESNOFemale Patient: How many pregnancies have you had?Female Patient: How many miscarriages have you had? (spontaneous and elective)Female Patient: How many children are living?Allergies (Name of the Medication and Reaction) *May We Leave Messages on Your Voicemail? *YESNOCurrent Medications (Name of medication, Strength (mg), Directions For Use) *[Example: Losartan 50mg take 1 tab everyday] List any medication, including vitamins, aspirin and supplements. You can also bring in your own list on paper.Insurance Policy *Insurance Policy Number *If no insurance please type in "none"PhoneSubmit
