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Laboratory
Activate COVID Test
Dialysis
Our Team
View My Result
In-Person
Clinic
Patient Forms
New Patient Registration Form
Patient Intake Questionnaire
Activate COVID Test
Reason For Visit
Post Medical History
Anxiety/Depression
Back Problems
Epilepsy
High Cholesterol
Osteoporosis
Blood Disorders
Glaucoma
Kidney Disorder
Stroke
Arthritis
Cancer
Heart Disease
Liver Disorder
Skin Disorder
AIDS/HIV
Diabetes
Hypertension
Lung Disorder
Thyroid Disorder
Medications
Name
Dose
Select
1
2
3
4
Frequency
Select
1
2
3
4
Name
Dose
Select
1
2
3
4
Frequency
Select
1
2
3
4
Name
Dose
Select
1
2
3
4
Frequency
Select
1
2
3
4
Name
Dose
Select
1
2
3
4
Frequency
Select
1
2
3
4
Allergies
Name of Medication
Reaction
Allergies
History
Colonoscopy
Women's Health
Last Pap Date
Last Mammogram Date
Family History
Do you have a family history of any of the following conditions?
Alcoholism
Back Problems
Diabetes
High Blood Pressure
Lung Disease
Anemia
Cancer
Genetic Disorder
High Cholesterol
Osteoporosis
Anxiety disorder
Blood disorders
Glaucoma
Kidney Disorder
Stroke
Arthritis
Depression
Heart Disease
Liver disorder
Thyroid Disorder
If you checked any of the above conditions, Please identify who in you family has the condition
Social History
Tobacco Use
Current
Former
Never Packs per day
Alcohol Use
Yes
No
Currently sexually active?
Yes
No
Would you like STD screening today?
Yes
No
Recreational drug use
Yes
No
Caffeine intake
# of drinks/day
How often do you exercise? # times/week
Call
Call
242-433-4809
242-816-8869
