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Complete Care Medicine & Spa

Registration Form

General Information


First Name *

Middle Name

Last Name *

Address

State

Zip Code

Referred by

Phone Number

Cell Number

Email Address

Date of Birth (YYYY-MM-DD)

Age

Sex

Place of Birth (City/State/Country)

Allergies to medicine/foods/etc

Where did you spend most of your life growing up?


Insurance Information


Insurance Provider Name

Address

State

Zip Code

Customer Service/Provider Phone Number

Subscriber Number

Group Number


Wellness


When did you last feel your best? (Year or Age)

What are your main health concerns?

Past Medical History (Please list any hypertension, high cholesterol, thyroid issues, etc.)

Past Surgical History (Please give procedures and dates)

Medications

Supplements


Social History

Smoking
NoYes

How much?

Alcohol
NoYes

Average daily/weekly intake

Recreational Drug Use
NoYes

How much?

Married
NoYes

Significant Other
NoYes

Sexually Active
NoYes

Birth control method (if applicable)

Occupation

How many hours/week

How long

Child 1 - Name

Age

Child 2 - Name

Age

Child 3 - Name

Age

Child 4 - Name

Age

Child 5 - Name

Age

Stress Level

Most common foods eaten

Most common beverages (include caffeinated drinks)

Exercise and other physical activity (include amount of time)


Family History

Please provide a family history of medical conditions for the following people. You do not need to include names.

Father

Mother

Paternal Grandfather

Maternal Grandfather

Paternal Grandmother

Maternal Grandmother

Brothers

Sisters

Paternal Uncles

Maternal Uncles

Paternal Aunts

Maternal Aunts