Demographics: Please fill out completely Each page is FRONT AND BACK Ethnicity: Cacausian African American Arabic Hispanic Asian Address Information: Phone: Mobile: Is it ok to leave a message on your home phone? Yes No On your cell phone? Yes No Consent to text? Yes No Employment Information: Preferred Pharmacy Location (cross-streets): Billing Reference: via Portal via Mail Insurance Information: Social History Marital Status: Single Married Separated Divorced Widowed Tobacco: Current Former Never If Current Former: Alcohol: Current Former Never If Current Former: Illicit or Recreational Drugs: Current Former Never If Current Former: Your Medical History Anemia Anxiety Disorder Arthritis Asthma Autoimmune Disease Bleeding Disorder Blood transfusion Bronchitis COPD Cancer Coronary Artery Disease Deep Vein Thrombosis Depression Diabetes Diverticulitis Eye disease Gout Headaches Other Heart disease Hepatitis High Cholesterol Hypertension Kidney disease Kidney Stones Liver disease Morbid Obesity Obstructive Sleep Apnea Psychiatric disorder Pulmonary Embolism Reflux/GERD Seizures/Epilepsy Stomach/intestinal disease Stroke Thyroid disease Tuberculosis Other (Please Explain) Surgical History List any surgeries you have had and the approximate date. Example: tonsillectomy, appendectomy, gallbladder removal, tubal ligation, breast surgery/biopsy, laparoscopy. Submit
