Log In

  
Secure Online Forms: Patient History
 
For your convenience, we have created the online Patient History form below.
 

 
No Known Allergies
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Recent Weight Gain
Recent Weight Loss
Decreased Exercise Tolerance
Fatigue
Loss of Appetite
Hair Loss
Macular Degeneration
Cataracts
Glaucoma
Wear Glasses
Wear Contacts
Partial Complete
Difficulty Speaking
Cough
Shortness of Breath at Rest
Shortness of Breath with Exercise
Sleep Apnea
Chest Discomfort
Palpitations
Swelling in the feet and legs
Nausea
Blood in Stool
Stomach Ulcers
Arthritis
Loss of Strength
Previous Stroke
Confusion
Dizziness
Headaches
Seizures
Anxiety
Stress
Depression/Anxiety Disorder
History of Drug Abuse
History of Alcohol Abuse
Hyperthyroidism
Hypothyroidism
Bleeding Disorder
Seasonal Allergies
Food Allergies
Decreased Walking Endurance
Foot Pain or Numbness
Painful cramping or sharp pains of the legs or hips with physical activity
Foot or toe wounds that are slow to heal