CLINIC PATIENT INFORMATION SHEET FORMPlease fill out the below options and click submit to send us an auto-filled in PDFFull Name(Required) Full Name Date(Required) MM slash DD slash YYYY DOB(Required) Month Day YearGender(Required) Male FemaleAllergiesMedication 1Dosage 1How Often 1Medication 2Dosage 2How Often 2Medication 3Dosage 3How Often 3Personal Medical History (Please Check All That Apply)(Required) ADHD Alcoholism Allergies, Seasonal Anemia Anxiety Arrhythmia (irregular heartbeat) Arthritis Asthma Bipolar Bladder Problems / Incontinence Bleeding Problems Cancer Headaches Crohn's Disease COPD/ Emphysema Dementia Depression Diabetes: 1 or 2 Diverticulitis DVT (Blood Clot) GERD (Acid Reflux) Glaucoma Heart Disease Heart Attack (MI) Hiatal Hernia High Blood Pressure Kidney Stones Kidney Disease High Cholesterol HIV Hepatitis Irritable Bowel Syndrome Lupus Liver Disease Macular Degeneration Neuropathy Osteopenia/Osteoporosis Parkinson's Disease Peripheral Vascular Disease Peptic Ulcer Psoriasis Pulmonary Embolism (PE) Rheumatoid Arthritis Seizure Disorder Sleep Apnea Stroke Thyroid Disorder Ulcerative ColitisPlease Check All That ApplyCancer Type (If Applicable)Other Medical Conditions Not Listed Above:Surgery Name 1Date of Surgery 1 Month Day YearSurgery Name 2Date of Surgery 2 Month Day YearSOCIAL/CULTURAL HISTORY:Education Level:(Required) Elementary High School College GraduateAre there any vision problems that affect your communication?(Required) Yes NoAre there any hearing problems that affect your communication?(Required) Yes NoCurrent Living Situation (Select all that apply):(Required) Single Family Household Multi-Generation Family Homeless Shelter Skilled Nursing Facility OtherSmoking/Tobacco Use: Current Past NeverTobacco TypeDaily Tobacco AmountTobacco Number of YearsAlcohol Use: Current Past NeverDrinks Per WeekRecreational Drug Use Current Past NeverRecreational Drug Use TypeAre you sexually active? Yes NoAre there any personal problems at home, work, or school you would like to discuss? Yes NoAre there any cultural or religious concerns you have related to our delivery of care? Yes NoAre there any financial issues that directly impact your ability to manage your health? Yes NoHow often do you get the social and emotional support you need? Always Usually Sometimes Rarely NeverComments (Please feel free to comment on any answers marked “yes” above):Family HistoryFather Birth Year Month Day YearFather Deceased Year Month Day YearFather Medical History Alcoholism Anemia Asthma Arthritis Bipolar Disorder Cancer COPD/Emphysema Dementia Depression Diabetes 1 or 2 DVT (Blood Clot) Heart Disease High Cholesterol High Blood Pressure Kidney Disease Migraines Osteoporosis Stroke Thyroid DisorderElaborate if Selected OtherMother Birth Year Month Day YearMother Deceased Year Month Day YearMother Medical History Alcoholism Anemia Asthma Arthritis Bipolar Disorder Cancer COPD/Emphysema Dementia Depression Diabetes 1 or 2 DVT (Blood Clot) Heart Disease High Cholesterol High Blood Pressure Kidney Disease Migraines Osteoporosis Stroke Thyroid DisorderElaborate if Selected OtherSiblings and Their Medical History If ApplicableList other medical providers you see regularly (i.e. Cardiologist, Mental Health Provider, Kidney Doctor, Dentist, etc.)Signature Full Name Date(Required) Month Day Year 60185