Patient Registration Date Of Birth Time Preference 123456789101112 00102030405060 AMPM SingleMarriedDivorcedWidowedLegally Seperated Select any of the following medical conditions that you currently have or had: AnxietyAtrial FibrillationAsthmaBenign Prostate HyperplasiaBone Marrow TransplantBreast CancerColon CancerCoronary ArteryCOPDDepressionDiabetesEnd StageGERDHearing LossHepatitisHigh ColestrolHigh Blood PressureHIV/AIDsHyperthyroidismLeukemiaLung CancerLymphomaProstate CancerRadiationStrokeSeizuresNoneOther Select any of the following surgeries you have had: AppendixBladder (Cystectomy)Breast: BiopsyBreast LumpectomyBreast MasectomyBreast ReductionBreast AugmentationColon: Cancer ResectionColon: DiverticulitisColon: Inflammation Bowel DiseaseGallbladderHeart: Coronary Artery BypassHeart: PTCAHeart Mechanical ValveHeart: Biological ValveHeart: TransplantJoint replacement KneeJoint replacement HipKidney BiopsyKidney NephrectomyKidney Stone RemovalKidney TransplantOvaries: EndometriosisOvaries: Ovarian CystOvaries: Ovarian CancerProstate: Prostate CancerProstate: Prostate BiopsyProstate: TURPSkin: BiopsySkin: Basal Cell CarcinomaSkin: Squamous Cell CarcinomaSkin: MelanomaSpleenTesticlesUterus: FibroidsUterus: Uterine CancerOtherNone Select any of the following conditions you currently have or had: AcneActinic KeratosisAsthmaBasal Cell CarcinomaBlistering SunburnsDry SkinEczemaFlaking or itchy scalpHay Fever/ AllergiesMelanomaMelasmaPoison IvyPrecancerous Moles/ Dysplastic NevusPsoriasisSquamous Cell CarcinomaOtherNone Do you wear sunscreen? YesNo Do you tan in a tanning bed? YesNo Do you have family history of Melanoma? YesNo Do you pre-medicate with antibiotics before procedures? YesNo Do you take blood thinners? YesNo Social History Current every day smokerCurrent some day smokerFormer smokerNever Smoker Do you drink alcohol? YesNo Have you received the following: Shingles vaccine (over 65)Pneumonia vaccine (over 65)Age 9-13: A series of 3 HPV (Human Papillomavirus) Flu Vaccine YesNo Advance Care (Over 65) Do you have a health proxy in the event you are unable to make your own medical decisions? YesNo Which statement reflects your wishes on advanced care recommendations? Do Not Intubate: I do not wish to have a breathing tube, even if it is necessary to save my life.Do Not Resuscitate: If my heart were to stop, I do not wish to have chest compressions or an automated external defibrillator to restart my heart, even if it is necessary to save my lifeFull Cardiopulmonary Resuscitation: I want full cardiopulmonary resuscitation efforts to be made. How did you hear about us? FacebookGoogleNewsletterReferralOther
