Sarita Kansal, MD - Publicforms

Available Forms

APPOINTMENT REQUEST HIPPA NOTICE/CONSENT FORM MEDICAL INFORMATION FORM MEDICATION REFILL REQUEST PATIENT INFORMATION SHEET RECORDS RELEASE FORM

MEDICAL INFORMATION FORM

Please fill out completely. DO NOT leave any blanks, if anything does not pertain to you, please put "N/A."

DO YOU OR HAVE YOU EVER HAD:

DIABETES *

YES

HEART DISEASE *

YES

ARTHRITIS *

YES

LUNG PROBLEMS: *

YES

KIDNEY DISEASE *

YES

HIGH BLOOD PRESSURE *

YES

CANCER *

YES

THYROID PROBLEMS *

YES

HEIGHT: *

WEIGHT *

DO YOU HAVE ANY ALLERGIES TO:

FOOD *

IF, NONE PUT N/A

DRUGS *

IF NONE, PUT N/A

IODINE *

YES

ANY OTHER ALLERGIES? *

IF NONE, PUT N/A

DO YOU CURRENTLY SMOKE? *

YES

IF YES, HOW MANY PER DAY, & FOR HOW MANY YEARS? *

IF NO, PUT N/A

HAVE YOU EVER SMOKED? *

YES

IF YES, HOW MANY PER DAY, & WHEN DID YOU QUIT? *

IF NO PUT N/A

DO YOU DRINK ALCOHOLIC BEVERAGES? *

YES

IF YES, HOW MUCH A WEEK? *

IF NO, PUT N/A

HAVE YOU BEEN TREATED FOR DEPRESSION? *

YES

HAVE YOU BEEN TREATED FOR A PSYCHOLOGICAL PROBLEM? *

YES

IF YES TO EITHER ABOVE, LIST: *

IF NO TO BOTH, PUT N/A

ANY HISTORY OF DRUG OR SUBSTANCE ABUSE? *

YES

IF YES, LIST: *

ARE YOU AT RISK OF HIV/STD? *

YES

FAMILY MEDICAL HISTORY:

MOTHER IS: *

ALIVE

DECEASED

IF DECEASED, AGE & OF WHAT? *

IF ALIVE, PUT N/A

FATHER IS: *

ALIVE

DECEASED

IF DECEASED, AGE & OF WHAT? *

IF ALIVE, PUT N/A

SIBLINGS AGE AND ANY MEDICAL PROBLEMS: *

Please list your siblings age and any medical problems they may have. If you do not have any siblings, please put NA.

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING WITH STRENGTH & DOSE: *

DESCRIBE MEDICAL PROBLEM THAT BRINGS YOU TO OUR OFFICE: *

ANY OTHER SIGNIFICANT MEDICAL PROBLEMS THAT YOU WOULD LIKE TO BRING TO OUR ATTENTION? *

LIST ANY PAST SURGERIES: *

NAME *

* Required field