Patient Forms - LifeGaines Medical and Aesthetics

Patient Information

Full Name*

Street Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Marital Status*

Single
Married
Divorced
Widowed

Sex*

Male
Female
Other

Ethnicity*

Hispanic or Latino
Non Hispanic or Latino
Unknown

Date of Birth*

Age*

Student/Employer*

Employer Phone*

Employer Street Address*

Employer City*

Employer State*

Employer Zip Code*

Whom may we thank for referring you?

Family Doctor*

Preferred Pharmacy*

In case of emergency, who should be notified?*

Emergency contact relationship to patient*

Emergency contact phone number*

Legal Guardian if patient is under 18 years old

Legal Guardian's phone number

Legal Guardian's date of birth

New Patient Health Questionnaire

First & Last Name*

Date of Birth*

Age*

New or returning patient?*

New Patient
Established

PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.

What medical concerns bring you to our office?*

Marital Status*

Single
Married
Divorced
Widowed

Occupation (if retired, previous occupation)*

Are you disabled?*

Yes
No

Birthplace*

Do you exercise regularly?*

Yes
No

Have you ever smoked?*

Yes
No

Have you completed an advanced directive or do you have a living will?*

Yes
No

Do you drink caffeinated coffee, teas, or sodas regularly?*

Yes
No

Tell us a little about your home environment*

Are you under a lot of pressure at work or home? If yes, which one?*

Medical Information

Are you allergic to any drugs?*

Yes
No

Medications

List all medications that you are taking currently. Include over the counter, herbal or natural remedies.

Medical Illness or Conditions

List any chronic conditions which you have been diagnosed to have

Have you ever had or been diagnosed to have:

Select all that apply.

Specify other

Operations

Please list any surgery, hospital, and approximate year

Hospitalizations (other than operations)

Please list any reason, hospital, and approximate year

Family Medical History

Please List The Following for Each Family Member:

1. Relation (Father, Mother, Sister, Brother, Spouse, Children) 2. Age of Relative 3. Any Significant Illness 4. If Deceased, Cause. 5. Any Additional Comments.

Has Any Blood Relative Ever Had?

Check if yes and indicate relationship

What's Your Relationship to the Relatives With Above Condition(s)?

Immunizations*

Specify other

Have you ever had a blood or plasma transfusion?*

Yes
No

What is your weight now?*

What was your weight one year ago?*

What has been your maximum weight?*

When were you that maximum weight?*

Medical History Form

Patient Information

New Patient Health Questionnaire

Medical Information

Family Medical History