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Back Pain E-Visit
Billing Question
Blood Pressure Log
Blood Sugar Readings
Cold/Flu/Sinus/Cough//Throat/Respiratory Infection E-Visit
Comments or Suggestions
Conjunctivitis/Pink Eye E-Visit
Coronavirus Screening 2020
Covid Vaccine Waitlist Group 1 , 2 or 3
Covid Vaccine Waitlist Group 4
Depression Screening (PHQ9)
Flu Shot
Health Care Question
Hospitalization
Insurance Change Form
Lab Result Follow-up Question
Living Will/Health Power of Attorney
Medical History/Preventative Update
Medicare Shared Savings Letter
Medicare Wellness Exam
New Patient Medical History
New Patient Registration Form
Password - Patient Request for Secure Password
Patient Education Classes
Prescription Refill Request
Preventative Care
Quality Improvment
Referral Question
Specialist/ER/Hospital/Testing Update
Specialist/Urgent Care or Hospital Visits
Survey- Cary Adult Medicine
Urinary Tract Infection E-Visit
Yeast Infection E-Visit
New Patient Medical History
Todays Date
*
First Middle Last Name
*
Date of Birth
*
Allergies to Any Medications
*
Cipro/Levaquin
Doyxcyline
Keflex/Ceftin/Cephalosporin
Macrobid
Penicillin/Amoxicillin
Sulpha
Zpak/Biaxin/Erythromycin
Other
None
Please list other medications you may have an allergy to that are not included abovedication other than listed please list below
Use Return Key after each drug /dose/frequency to advance to next line
Have you had an allergic reaction to any of the following
*
Latex
Shellfish
Nuts
Anesthesia
None of above
Please list all prescription medications with dose and # of times taken daily
Have you ever had any of the following?
Anemia
Anxiety
Arthritis
Asthma
Atrial Fib or Flutter
Back or Neck Problems
Blood Clot leg or lung
Cancer
Congestive Heart Failure
COPD
Coronary Disease
COVID
Depression
Diabetes
Eating Disorder
Heart Attack
Heart Bypass or Stent
Hepatitis
High Blood Pressure
HIV or AIDS
Incontinence of Urine
Irritable Bowel
Kidney Problems
Liver Problems
Menstrual Problems
Osteoporosis
Reflux/GERD
Seizures
Sleep Apnea
STD's
Stroke
Thyroid Issues
Have you had any of these shots?
Covid
Flu shot some years
Flu shots yearly
Hepatitis A
Hepatitis B
Pneumonia
Shingles
Tetanus within 10 years
Surgical History Have you had any of the following?
*
Appendectomy
Breast Biopsy
Coronary Bypass
Gallbladder removal
Hernia repair
Hip replacement
Hysterectomy
Knee replacement
NO surgical procedures listed
Has any one in your family had any of the following?
Aneurysms
Blood Clots
Brain Cancer
Breast Cancer
Colon Cancer
Diabetes
Heart Problems
Hypertension
Mental Illness
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Stroke
Please list individual in your family had any of the above diseases and which disease they had
Smoking History
*
-- Please Select --
Never Smoked
Infrequent/Social Smoker
Former Smoker
Current Smoker
Other tobacco use
If a smoker how many years did you smoke and how many on average packs per day?
Alcohol Use
*
None
Social < 1 x week
Drink 2-3 days a week
Drink just weekends
Drink more than 3 days per week
Recreational Drug Use
*
-- Please Select --
Yes
No
Caffeine Use
*
-- Please Select --
None
1 cup a day
2 cups a day
3 cups a day
More than 3 cups a day
How many times a week do you exercise
-- Please Select --
None
1 day
2 days
3 days
4 days
5 days
6 days
7 days
What type and for how long do you exercise?
For Females Type of Birth Control
-- Please Select --
Condoms
Depoprovera
Diaphragm
IUD
Menopause
Oral Pills
Patch
Ring
Hysterectomy
None
Not Applicable
Last Colonoscopy
-- Please Select --
Never
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Before 2010
Next Colonoscopy Due
-- Please Select --
This Year
1-2 years
3-4 Years
5 Years
6-9 Years
10 years
Not sure
For Females Last Mammogram
-- Please Select --
This Year
1-2 years
2-3 years
Over 3 years
None
For Females Last Bone Density Test
-- Please Select --
Never
< 1 year
1-2 years
2-3 years
Over 3 years
For Females Last Pap Smear
-- Please Select --
Never
< 1 year
1-2 years
2-3 years
3-5 years
> 5 years
For Males Last PSA Prostate Blood test
-- Please Select --
Never
< 1 year
1-2 years
2-3 years
> 3 years
Last Physical Exam
-- Please Select --
Never
< 1 year
1-2 years
2-3 years
3-4 years
4-5 years
> 5 years
Last blood test for cholesterol
-- Please Select --
Never
< 1 year
1-2 years
2-3 years
3-4 years
4-5 years
Please list any religious or cultural needs ?
Is there any additional history you would like to provide today?
* Required field
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