Form

Patient Form

Patient General and Medical History Form

PATIENT NAME *

Gender *

DATE OF BIRTH *

mm/dd/yyyy

AGE *

EMAIL & PHONE & HOME ADDRESS *

INSURANCE NAME, GROUP ID, MEMBER ID & EMPLOYER NAME: *

DATE APPOINTMENT *

mm/dd/yyyy

TIME OF APPOINTMENT *

PLEASE DESCRIBE WHY YOU WANT TO SEE THE DOCTOR *

CURRENT MEDICAL PROBLEMS *

For Example: Diabetes, High blood pressure, heart disease, stroke, heart attacks, seizures, cholesterol, thyroid, etc...

LIST ANY SURGERIES OR HOSPITALIZATIONS IN YOUR LIFE TIME *

HOME MEDICATIONS and the prescribing doctors name *

Name & number of pharmacy or DME company *

Discontinued/Completed Medications & Treatments *

ALLERGIES *

Social and Functional History *

(Smoking, Alcohol, Diet, Exercise, Sleep Habits, Profession/Job)

DOES YOUR PARENTS/GRAND PARENTS/SIBLINGS HAVE ANY MEDICAL CONDITIONS *

For example: Diabetes, High blood pressure

DO YOU HAVE ANY ADDITIONAL SYMPTOMS *

For Example: weakness, fever, headache, vision or hearing problems. chest pain, difficulty breathing, abdominal pain, joint pain, back pain. Depression, anxiety, sleep problems, snoring etc...

If required I/we give consent to consult with doctor through audio-video conference. For this service your insurance will be billed for payment if your insurance allows: I/we give consent to obtain medical records from other healthcare providers to help in coordination of care. *

Electronic Signature of patient or Authorized representative *

Already a member? Sign In

Trusted Sleep Medicine Consultants since 2011

Online Clinic

Patient Form