Please list all medical conditions you have.
Please list all surgeries and procedures you have undergone (procedure type, date, location / facility where it was performed).
Physicians: Please tell us about other physicians you see or have seen in the past (full name, specialty, reason, address / phone / fax).
Please list all drugs / substance you are allergic to (drug/substance, type of reaction).
Please list all medications you're taking (drug name, dose, frequency, reason for use).
Please list the medical history of family members (relative, diagnosis, approximate age at diagnosis).
Please tell us if you're single, married, employed, occupation, use of tobacco products (which ones, frequency), alcohol, recreational drugs.
IF applicable (insurance provider, complete name of primary member, complete name of covered member, member ID, group ID).
Please enter your pharmacy information (Name of pharmacy, complete address, phone and fax).
If there is a certain imaging center you would like orders (e.g. X-ray, CT, MRI) to, please provide the complete name, address, phone, and fax number. Type 'n/a' if no preference.
Please convey any specific questions, or requests you may have.
E.g. Google, Instagram, Facebook, X/ Twitter, referral from a family member, friend or another physician.
