New Patient Intake Form Question Title * 1. Full Name Question Title * 2. Address Question Title * 3. Email Question Title * 4. Phone Question Title * 5. Sex Male Female Question Title * 6. What's your Date of Birth Question Title * 7. Have you been treated for any conditions in the last year? Yes No Question Title * 8. If yes, please describe Question Title * 9. Date of last physical exam Question Title * 10. Is there a chance that you are pregnant? Yes No Question Title * 11. What medications are you taking and for what conditions? Question Title * 12. Are you allergic to any medication? Yes No Question Title * 13. If yes, please describe Question Title * 14. Have you ever: Broken bones Been hospitalized Been in an auto accident Had sprains/strains Been struck unconscious Had surgery Have a pacemaker Have a defibrillator Question Title * 15. If you checked any boxes above, please describe Question Title * 16. Please mark any condition that you now have or you have had in the past: Severe headaches Hypertension Stroke Epilepsy Fatigue Dizziness/Fainting Anemia Shortness of breath Asthma Gout Ears ring Chest pain/angina Heart Palpitations Heart murmur Arrhythmia Congenital heart disease Rheumatic or Scarlet Gall stones Pancreatitis Liver disease Arthritis Allergies Kidney Stones Renal Disease Diabetes Endocrine Disease Urinary or genital problems Prostate problems Sexual dysfunction Ovarian cysts Digestive problems HIV/AIDS Cancer Claudication Ulcer Venereal disease Mental illness Alcohol/Drug problems Low back pain Shoulder pain Neck Pain Knee Pain Numbness/tingling in arms/hands Numbness/tingling in legs/feet Question Title * 17. Has anyone in your immediate family (mother, father, grandparents, brothers, sisters, children) had the following Heart Disease Hypertension Stroke Cancer Diabetes Epilepsy Glaucoma Bleeding Disorders Kidney Disease Thyroid Disease Question Title * 18. Ask Dr. Tyra Next
