NEW PATIENT FORM

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone *

(###)

###

####

Secondary Phone

(###)

###

####

Spouse Name

First Name

Last Name

Spouse Date of Birth

MM

DD

YYYY

Would you like to be added to our VIP email list to be notified of exclusive events and promotions? *

YES

NO

Radio 1Are you interested in talking to our Esthetician about skin care treatments or products? *

YES

NO

Person to notify (in case of emergency): *

First Name

Last Name

Phone *

(###)

###

####

I have read & understand the Insurance Acknowledgement *

I accept the Insurance Acknowledgment as stated above.

Are you allergic to Latex? *

YES

NO

Do you take aspirin/ibuprofen/Motrin on a daily basis? *

YES

NO

Do you currently smoke? *

YES

NO

If no, have you smoked in the past?

YES

NO

Date you quit smoking?

MM

DD

YYYY

Do you currently drink alcohol? *

YES

NO

Do you use Recreational Drugs? *

YES

NO

Are you retired? *

YES

NO

Are there diseases that run in your family? *

YES

NO

Daily chronic cough *

YES

NO

DON't KNOW

Sputum, phlegm or mucus productiOn *

YES

NO

DON't KNOW

Asthma, wheezing *

YES

NO

DON't KNOW

Bronchitis, Emphysema, C0PD *

YES

NO

DON't KNOW

Tuberculosis (TB) *

YES

NO

DON't KNOW

Can you walk 2 flights of stairs without stopping to catch your breath? *

YES

NO

DON't KNOW

Chest pain, angina, heart attack *

YES

NO

DON't KNOW

Leg swelling, CHF *

YES

NO

DON't KNOW

Asthma, wheezing *

YES

NO

DON't KNOW

Shortness of Breath *

YES

NO

DON't KNOW

High Blood Pressure, Hypertension *

YES

NO

DON't KNOW

Heart Murmur, rheumatic fever *

YES

NO

DON't KNOW

Cramping in legs when walking *

YES

NO

DON't KNOW

Phlebitis (blood clots) *

YES

NO

DON't KNOW

Do you sJeep on more then 2 pillows? *

YES

NO

DON't KNOW

Do you wake up short of breath? *

YES

NO

DON't KNOW

Diabetes, high/low blood sugar *

YES

NO

DON't KNOW

Thyroid problems, heat or cold tolerance *

YES

NO

DON't KNOW

Bleeding Problems *

YES

NO

DON't KNOW

Anemia *

YES

NO

DON't KNOW

Skin Cancer *

YES

NO

DON't KNOW

Hiatal hernia, heartburn *

YES

NO

DON't KNOW

Ulcers, vomiting blood *

YES

NO

DON't KNOW

Hepatitis, jaundice *

YES

NO

DON't KNOW

Liver disease, cirrhosis *

YES

NO

DON't KNOW

Could you be pregnant? *

YES

NO

DON't KNOW

Difficulty passing urine *

YES

NO

DON't KNOW

At risk for AIDS or VD *

YES

NO

DON't KNOW

Physical limitations or prosthesis *

YES

NO

DON't KNOW

Arthritis *

YES

NO

DON't KNOW

Depression *

YES

NO

DON't KNOW

Seizures, convulsions, fainting, epilepsy *

YES

NO

DON't KNOW

Stroke, fleeting blindness, weakness *

YES

NO

DON't KNOW

Paralysis *

YES

NO

DON't KNOW

Psychiatric Treatment *

YES

NO

DON't KNOW

Headaches, unexplained weight loss or fatigue *

YES

NO

DON't KNOW

Cold Sores *

YES

NO

DON't KNOW

I have read & understand the New Patient Acknowledgement *

I accept the New Patient Acknowledgement as stated above

Name *

By typing your name below you are digitally signing the document being submitted to Dr. Randy Tate M.D.

First Name

Last Name

Date *

MM

DD

YYYY