Dr. Danielle Hamilton Patient Intake Form

Dr. Danielle Hamilton/Dr. Fan Mo
New Patient Registration Form Patient Name:__________________________________ DOB: __________________ Gender: ☐ M ☐ F Address:______________________________________________________________________________ Phone Number: Cell: ________________________ Home:______________________ Work: _______________________ email: _______________________________________________________________________________ Past Medical History: (have you ever had the follow conditions, please check yes or no)
Heart disease Diabetes Blood clots Cancer Asthma/COPD Stomach Ulcer Arthritis Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ High Blood Pressure Stroke Depression/Anxiety Autoimmune conditions Glaucoma Thyroid disease Anemia Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Irregular heart beat Kidney disease High cholesterol Hepatitis AIDS/HIV Skin conditions Chronic infection Yes / No ☐ ☐
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If you answered ‘Yes’ to any questions above, please provide details regarding investigations, specialist appointments, and treatments: _____________________________________________________________________________________
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_____________________________________________________________________________________ Please list all other medical problems/illnesses that you are seeing or have seen a physician for: _____________________________________________________________________________________
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_____________________________________________________________________________________ Past Surgical History: Date:___________________________Surgery:______________________________________________ Date:___________________________Surgery:______________________________________________ Date:___________________________Surgery:______________________________________________ Medication list:
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_____________________________________________________________________________________ Dr. Danielle Hamilton/Dr. Fan Mo
Allergies to Medications/Environmental: ___________________________________________________ Family History: Heart disease Diabetes Blood clots Cancer Asthma/COPD Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ High Blood Pressure Stroke Depression/Anxiety Autoimmune condition Glaucoma Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Thyroid disease Kidney disease High cholesterol Skin cancer Yes / No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ If you answered ‘Yes’ to any questions above, please provide details regarding family member(s), diagnosis, age at diagnosis and/or death: _____________________________________________________________________________________
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_____________________________________________________________________________________ Social History: Occupation: _________________________________________________________________________ Insurance coverage for medications: ☐ Yes ☐ No Marital Status: Single / Married / Divorced; Number of Children: _____________________________ Alcohol consumption: _________drinks/week Smoking: ☐ Yes ☐ No If Yes, number of cigarettes per day _______, for ____________ years. Your Pharmacy:________________________________________________________________________ Health Screening: When was your most recent annual physical exam: _________________________________________ Last Tetanus shot: _____________________________________________________________________ If applicable: Most recent pap smear:________________________ Most recent Mammogram: _________________ Colonoscopy or FOBT test: ______________________ Bone Mineral Density: _____________________ PSA testing: _______________________ Patient Signature: _________________________________________________________________