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Personal Details

First Name*

Middle Initial

Last Name*

Profile Picture*

Date of Birth*

Gender*

Email Address*

Mobile Number*

Marital Status*

Street Address*

Floor / Suite

Country*

State*

City*

Zip Code*

City*

State*

Race*

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Login Details

Username*

Password*

Confirm Password*

Emergency Contact Details

Name

Relationship

Cell Number

Risk Factors

Have you ever had high Tryglyceride or Cholesterol levels?

Yes

No

Do you have any drug habit/addiction?

Yes

No

Are you exercise regularly?

Yes

No

Are you Overweight?

Yes

No

Are you a current/previous smoker?

Yes

No

Please estimate the amount of coffee, tea and/or caffeinated drinks daily?

If so, how many packs per day?

How many years have you smoked?

Do you drink Alcohol?

Yes

No

If so, estimate the amount you drink in one week.

Past Surgeries
Have you had an opereation on any of the following?

Appendix

Tumor of any Kind

Hernia

Gallbladder

Varicose Veins

Hemorrhoids

Kidney

Thyroid

Chest

Tonsils

Breast

Other

Illnesses
Check any of the following medications ypu are presently taking or have taken in the past year?

Anemia

Blood Transfusions

Nervous Breakdown

Bleeding Disorder

Hernia

Varicose Veins

Jaundice

Hemorrhoids

Ulcer

Diabetes

Colitis

Gallbladder Disease

Cancer

Arthritis

Tuberculosis

Migraine

Bone Disease

Hepatitis

Blood Clots or Phlebitis

Back Trouble

Pneumonia

Heart Disease

Asthma or Hay Fever

Skin Disease

Heart Murmur

Convulsion

Allergy or Drug Reactions

High Blood Pressure

Kidney Stone

Other

Medication
Have you ever had any of the following?

Cortisone or Steroids

Hormones

Blood Pressure Pills

Sleeping Pills

Typhoid

Asthma Medicine

Heart Medicine

Arthritis Medicine

Antibiotics

Tranquilizer or Nerve Pills

Pain Medicine

Diet Pills

Diuretic

Other

Hospitalization
If you have been hospitalized for any non-surgical illness, please list below (excluding childbirth).

Hospital

Year

Diagnosis

Kidney & Bladder

Difficult or Painful Urination

Blood in Urine

Can't Hold Urine

Very Frequent Urination

Kidney Disease

Kidney Stones

Protein in Urine

frequent infections

Sugar In Urine

Get up more than once at night to urinate

Muscles, Bones & Joints

Deformities

Muscle Weakness

Pain in Joints

Chronic Pain in Back

Swelling in Joints

Gout

Nervous System

Frequent or Severe Headaches

Head Injury

Convulsion / Eplispy

Numbness or Tingling

Feel Sad or Depressed

Dificulty Sleeping

Suicidal thoughts

Severe Anxiety

Desired Psychistric Help

Weakness

Immunization

Have you ever had polio?

Yes

No

Did you ever had COVID-19?

Yes

No

Have you been tested for COVID-19?

Yes

No

Have you been in close contact (within 6 feet) with someone who is diagnosed with COVID-19?

Yes

No

Test Date

Test Result

Are you clear of COVID-19 now?

Since which date?

Last Injection Covid-19

Last Injection Polio

Last Injection Tetanus

Last Injection Tuberculosis

Last Injection Peptide

Genitals

Menstrual Period Began Age

Menstrual Period Began Date

No Of Pregnancies

No Of Normal Deliveries

No Of Premature Deliveries

No Of Miscarriages

No Of Abortions

No Of Living Children

Last Pap Snear Date

Birth Control Method

Do You Know How To Examine?

Your Breasts

Abnormal Pap Snear

Unusual Vaginal Discharge

Irregular Periods

Abnormal Bleeding

Pain on Intercourse

Pelvic Pain

Problems With Sex

Breast Lumps

Nipple Discharge

Veneral Disease

Genitals

Sores On Penis

Discharge From Penis

Prostate Gland Trouble

Difficulty Voiding

Impotence

Veneral Disease

Personal Details

First Name*

Middle Initial

Last Name*

Profile Picture*

Email Address*

Gender*

Male

Female

Date of Birth*

Languages

Arabic

Bengali

Chinese

English

French

Hindi/Urdu

Korean

Russian

Spanish

Street Address*

Country*

State*

City*

Zip Code*

City*

State*

Profession Details

Specialities

Adolescent Medicine

Allergy & Asthma

Allergy & Immunology

Bariatrics

Cardiology

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General Practice

Geriatrics

Gynecologic Oncology

Gynecology

Hair Restoration

Healthcare Professionals

Holistic Medicine

Infectious Disease

Integrative Medicine

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Interventional Pulmonology

LASIK Surgery

Legal Medicine

Nephrology & Dialysis

Neurology

Obstetric Medicine

Obstetrics & Gynecology (same database)

Occupational Medicine

Oncology

Ophthalmology

Pain Management

Pediatric

Pediatric Rheumatology

Pediatrics

Podiatry

Preventive Medicine

Psychiatry

Pulmonology

Rheumatology

Sleep Medicine

Sports Medicine

Substance Abuse

Travel Medicine

Urgent Care

Urogynecology

Urology

Wound care

Qualification

DDS

DMD

DO

DPM

EdD

MBBS

MBChB

MD

MDCM

PharmD

PhD

PsyD

License Number*

Individual NPI Number*

Group NPI Number*

Floor / Suite*

PTAN Number*

Working Hours

From

To

Monday

Tuesday

Wednesday

Thursday

From

To

Friday

Saturday

Sunday

Work Phone*

Cell Phone

Practice Starting Date*

Fee for Service*

Profession Overview*

Organization Details (if any)

Name

Street Address

Floor / Suite

Country

State

City

Zip Code

Zip Code*

City*

State*

Emergency Contact Details

Name*

Relationship*

Cell Number*

Practice Manager

Manager Name*

Manager Email*

Manager Phone*

Payment Details

Date

Payment Method

Payment Package

Login Details

Username*

Password*

Confirm Password*

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Personal Details

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Emergency Contact Details

Risk Factors

Past Surgeries Have you had an opereation on any of the following?

IllnessesCheck any of the following medications ypu are presently taking or have taken in the past year?

MedicationHave you ever had any of the following?

HospitalizationIf you have been hospitalized for any non-surgical illness, please list below (excluding childbirth).

Kidney & Bladder

Muscles, Bones & Joints

Nervous System

Immunization

Genitals

Genitals

Personal Details

Profession Details

Working Hours

Organization Details (if any)

Emergency Contact Details

Practice Manager

Payment Details

Login Details

Past Surgeries
Have you had an opereation on any of the following?

Illnesses
Check any of the following medications ypu are presently taking or have taken in the past year?

Medication
Have you ever had any of the following?

Hospitalization
If you have been hospitalized for any non-surgical illness, please list below (excluding childbirth).