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New Patient Form

First Name*
Last Name*
Phone*
Email Address*
Date of birth
please tell us about what medical symptoms or conditions bring you in
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HOW did yOu find out about US? 
Home address
apartment #
City
State
Preferred language
Marital status
occupation
do you smoke?
how often per week?
how Many Years?
do you consume alcohol?
How Often per week?
Do you have a history of alcohol abuse?
Recreational drugs?
what type?
Have you ever suffered from depression?
do you have any known allergies?
Please List allergies
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Allergic to bee stings?
current medications
Have you had any surgeries?
please list surgeries
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Do you take any current medications?
pharmacy name
Pharmacy address & Phone #
Medication #1
Dose
How often?
Medication #2
dose
How often?
Medication #3
dose
How often?
Do you have a history of the following?
Heart problem / chest pain
Medication
blood pressure
Medication
asthma
Medication
diabetes
Medication
High cholesterol
Medication
epilepsy / seizures
medication
anxiety / depression
Medication
dizziness / vertigo
medication
sleeping problems
medication
arthritis
medication
headaches
medication
thyroid problems
medication
substance abuse within last 6 months
Medication
ADHD
Medication

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