Last Name:*
First Name:*
Middle Name:
Phone Number*
DOB (YYYY/MM/DD):*
MaleFemaleOther
PHN:*
Address:*
City:*
Postal Code:*
Email*
Family Doctor:*
Emergency Contact Name / Relationship to you:*
Emergency Contact's Phone Number:*
Acid Reflux
AIDS/HIV
Anxiety
Arthritis Osteo/Rheumatoid
Back pain
Bleeding disorders
Blood clot
Cancer
Cholesterol
Circulation
Diabetes (Type 1/2)
Fibromyalgia
Gout
Heart Attack
Heart disease
Hepatitis A / B / C
Hernia
High blood pressure
Kidney problems
Liver problems
Lung problems
Lupus
Migraines
Osteoporosis
Prostate
Psoriasis
Stroke
Thyroid
Tuberculosis
Other
Adhesive tape
Aspirin
Codeine
Iodine
Latex
Local anesthetics
Metal
Penicillin
Are you pregnant? YesNo
Do you exercise? YesNo
If yes, please describe:
Do you smoke? RegularSociallyNever
Do you drink alcohol? RegularSociallyNever
Any recreational drugs? RegularSociallyNever
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Signature*:
Patient Name*:
Date*:
