Primary Care Physician

Patient First Name *

Patient Preferred Name

Is this your legal name?

Marital status

Patient Date of birth *

This Appointment Is For... *

Chose clinic because I was referred to the clinic by (please check one box):

If you selected 'Other,' please specify

If you selected referral whom may we thank for referring you?

RESPONSIBLE PARTY (If Different from Patient)

Name of Responsible Party

Relationship to Patient

Relationship to patient

PAST MEDICAL HISTORY

Check all conditions that apply to you:

Specify any other disease

Date of Last Chest X-ray

Are you currently pregnant?

Number of Pregnancies

Last Menstrual Period

Are they regular?

Pain Associated?

Delivery Type

Natural Delivery

C-Section

Please list all medications you are currently taking

Select one of the following

Inactive: no regular physical activity with a sit-down job

Light Activity: no organized physical activity during leisure time

Moderate Activity: Occasionally involved in activities such as weekend golf, tennis, jogging, swimming, or cycling

Heavy Activity: consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling, or active sports at least three times per week

Vigorous Activity: Participation in extensive physical exercise for at least 60 minutes per session, 4 or more times per week

What problem are you seeing the doctor for?

Is it on the right or left side?

How long have you had this problem (first time experienced the problem at any level)?

What treatment have you tried in the past?

What activities have you given up due to the problem?

How severe is the problem?

Are you on any medications for the problem?

Previous Hospitalizations or Surgeries

Allergies/Medication Allergies

Do you have a Sulfa Allergy?

Alcohol

Tobacco

Drugs

Have you been exposed to any of the following? (Check all that apply)

Fumes

Dust

Solvents

Noise

Hobbies and Activities

Family Medical History

Are you diabetic?

If yes, what type?

Last Fasting Blood Sugar Level

Do you have any implantable devices?

History of cellulitis?

Any current wounds, rashes, or skin infections?

If yes, please list any current wounds, rashes, or skin infections

Where is the pain?

Is the pain on the Left or Right side?

When did the pain start?

How often does the pain occur?

How would you describe the pain?

PATIENT CONSENT FOR COMMUNICATION

We have the ability to call or text you, reminding you of your appointments. If you would like to receive this feature in the future, please read the consent below and sign. Patients in our practice may be contacted via phone/text message to be reminded of an appointment, to obtain feedback on an experience within our office, and to provide general health reminders/information. I consent to receiving appointment reminders and other healthcare communications via telephone from Precure Alamogordo. I consent to receive text messages from Precure Alamogordo at my cell phone and any number forwarded or transferred to that number. The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information. I consent to receiving emails from Precure Alamogordo as stated above. The email that I authorize to receive email messages for general health reminders/feedback/information. I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.