Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Please use your TAB key to move to the next field. Thank you.


Personal Details
Name*:

Last name

First name

Mid name
Address*:
City:
Zip:
State:
Country:
Cell Phone#:* Alternate#:*
Email address*:
Birthday*:
Gender: Male Female Ethnicity:
Job title / Description: Employer:
Phone#:

Emergency contact person: Relationship:
Phone#:
Reason for visit / Consultation:
Medical History:
Please list all medical conditions you are being treated for:
Please list all surgeries you have had in the past:
Please list all medications and dosages that you take:
Please list all vitamins or supplements that you take:
Are you on birth control? Yes No
Allergic to any medications? Yes No
Do you smoke? Yes No
Height: Current Weight: Your goal weight:
The maximum you have ever weighed: Has your weight been stable for 6 months?
Women’s Health:
Number of pregnancies: Number of miscarriages:
Number of living children:
Ages of living children: Did you breastfeed? Yes No
Breast measurement and cup size: Desired breast cup size:
Do you have a history of breast cancer? Yes No
Family history of breast cancer? Yes No
Date of last mammogram:
Do you perform self breast exams? Yes No
Do you have any breast masses or abnormalities? Yes No Breast pain? Yes No
Review of systems: Do you have, or have you ever had, any of the following:
Head:
Headaches Yes No
Migraines Yes No
Epilepsy Yes No
Anxiety Yes No
Depression Yes No
Mental health disease Yes No
Eyes:
Contact lenses Yes No
Dry eyes Yes No
Excessive tearing Yes No
Retinal dettachement Yes No
Cataracts Yes No
Glaucoma Yes No
Visual field obstruction Yes No
Nose:
Difficulty breathing Yes No
Frequent bloody nose Yes No
Sinus infections Yes No
Blood:
Easy bruising Yes No
Blood clots Yes No
Body:
Unintentional weight loss Yes No
Cancer/tumor Yes No
History of radiation Yes No
History of chemotherapy Yes No
Arthritis Yes No
Muscle aches Yes No
Back pain Yes No
Fibromyalgia Yes No
Excessive scarring or keloids Yes No
Lungs:
Shortness of breath Yes No
Asthma Yes No
COPD Yes No
Emphysema Yes No
Bronchitis Yes No
Tuberculosis Yes No
Heart:
Heart disease Yes No
High blood pressure Yes No
High cholesterol Yes No
Chest pain Yes No
Murmur Yes No
Palpitations Yes No
Arrhythmia or Irregular heart
rhythm
Yes No
Ankle swelling Yes No
Sleep apnea Yes No
Organs:
Kidney disease Yes No
Liver disease Yes No
Infections:
Recent cough or cold Yes No
Fever Yes No
Night sweats Yes No
Hepatitis B/C Yes No
HIV Yes No
AIDS Yes No
Other immune deficiency Yes No
Other:
Any other info:
How did you find us? (check all that apply):
Google Realself Yelp Yahoo
Facebook Instagram Advertisement Magazine
Referred by:
Other:
*Patient signature:
Date: