Paul Kartchner, MD

Available Forms

***THIS FORM IS ONLY FOR DR. KARTCHNER'S PRACTICE IN TUCSON, ARIZONA. *** Please take a moment to provide your health history. Don't worry if a question doesn't apply to you or if you don't understand a question. We will be able to review this in person.

Prefix

First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Address *

City *

State *

ZIP *

Primary Phone # *

Alternate Phone #

Email Address

Marital Status

Spouse's Full Name

Health Insurance

Reason for Visit *

I am interested in: *

Monthly membership

Travel clinic only

Method of Payment *

Visa

MasterCard

Discover

American Express

ACH debit from bank account

We do not submit claims to insurance company. We do not accept cash or check at this time.

Emergency Contacts

Contact #1 Name

Contact #1 Phone

Relationship

Contact #2 Name

Contact #2 Phone

Relationship

Medical History

Medications

Please write down any vitamins, over-the-counter medications, herbal supplements, and anything else you take regularly.

Allergies

Please write down any allergies and their reactions.

Occupation

Do you use tobacco?

Yes

I used tobacco in the past but I don't anymore

This includes cigarettes, cigars, electronic cigarettes, hookah, dip, or any other tobacco products.

Alcohol (drinks per week)

Exercise (times per week)

Past Medical History

Please indicate if you have ever had any of these conditions.

Additional Medical History

Please add any important medical history we may have missed.

Surgical History

Please indicate surgery and year

Family History

Heart Disease

Diabetes

Stroke

Mental Illness

Cancer

Please indicate any health conditions present in your family

Other Family History

Please indicate any family history we may have missed.

Other Health Care Providers

Include ALL doctors or health care providers (or their medical practices) you have seen in the past 1 year - even if you do not intend to see them again.

* Required field

Available Forms

Patient Registration Form

Emergency Contacts

Medical History

Other Health Care Providers