Online Doctor Appointment Form

Patients Personal details

Fill the form below. We will contact you to confirm your appointment.
Full Name *
Phone Number *

Area Code Phone Number
Reason for appointment: *
Primary Language:
May we leave a message? *

Yes No
Date of Birth *

Day Month Year
Gender

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail Address *
Have you previously attended our facility *

Yes No
If Yes, state on which condition and when?
What specific problem brings you to our office today?
How long ago did this problem first start?
Did your pain or problem:

Begin all of a sudden Gradually develop over time
How would you rate your pain on a scale from 1-10?
0 being no pain, 10 being the worst pain possible)
How would you describe your pain?

no pain sharp dull aching burning radiating itching stabbing
Since the time your pain or problem began, has it:

Stayed the same Become worse Improved
What makes your pain or problem feel worse?

walking standing daily activities resing dress shoes high heels flat shoes any closed toe shoe running
What makes your pain or problem feel better?
What treatments have you had for this problem?
How has this problem affected your lifestyle or ability to work?
Was this problem caused by an injury?
If yes, was it work related?
Is there a family member or other person you would like for us to share your medical information?
If yes, please provide name:
Do you have a legal guardian or healthcare power of attorney?

Yes No
Emergency Contact Name:
Emergency Contact Phone number:
Relationship to Emergency Contact:
Primary Care Doctor:
Who referred you to us?
Pharmacy Name and Location:
Employer:
Occupation:
How much are you on your feet at work?
Do others depend upon you for their care?
Exercise:

Never Rare Occasional Weekly Several Times a Week Daily
Types of exercise:
Do you have a family history of:

Diabetes Cancer Heart Disease High Blood Pressure Stroke Coronary Artery Disease Thyroid Disease Rheumatoid Arthritis
Allergies:

none known Anesthesia tape latex shellfish iodine Medications
Have you ever had any of the following:
Acid Reflux:

Yes No
Anemia:

Yes No
Arthritis:

Yes No
Asthma:

Yes No
Back Trouble:

Yes No
Bladder Infections:

Yes No
Abnormal Bleeding:

Yes No
Blood Clots:

Yes No
Blood Transfusion:

Yes No
Bronchitis/Emphysema:

Yes No
Cancer:

Yes No
Diabetes:

Yes No
Fibromyalgia:

Yes No
Gout:

Yes No
Heart Attack:

Yes No
Heart Disease/Failure

Yes No
Hepatitis:

Yes No
HIV+/AIDS

Yes No
High Blood Pressure

Yes No
Kidney Disease:

Yes No
Liver Disease

Yes No
Low Blood Pressure:

Yes No
Migraine Headaches

Yes No
Mitral Valve Prolapse:

Yes No
Neuropathy:

Yes No
Open Sores:

Yes No
Pneumonia:

Yes No
Polio:

Yes No
Rheumatic Fever

Yes No
Sickle Cell Disease:

Yes No
Skin Disorder:

Yes No
Sleep Apnea:

Yes No
Stomach Ulcers:

Yes No
Stroke:

Yes No
Thyroid Disease:

Yes No
Tuberculosis:

Yes No
Pharmacy phone number:
Primary Insurance Company
Insurance ID#
Secondary Insurance Company
Secondary Insurance ID#
Please list all medications you are currently taking (include prescriptions, over-the-counter medications and herbal supplements):
Please list all prior surgeries:
Type of surgery and date.
Please list all prior hospitalizations (other than for surgery):
Reason for hospitalization and date.
Marital Status:

Single Married Partnered Separated Divorced Widowed
Use of Alcohol:

Never No Longer Use History of Alcohol Abuse Current Use
Use of Tobacco

Never Quit Smoke
Use of Recreational Drugs

Never Quit Current Use
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Signature:

Clear
Should be Empty:

Patients Personal details