Regular lower case
Your information is confidential. The more we know about your unique
background, the more we'll be able to help you. Filling out the form
ahead of time make your visit quicker and more complete.
How can Dr. Christian help you today?
What do you expect from this visit?
Regular lower case
 (CAPS)
Regular lower case
*Name: First, LAST
Street Address
Regular lower case
*Email:
City
Telephone
(cell & or home)
State
*Date of birth:
Zip/Postal code
Soc. security #
 Country
Person responsible
for account (self,
spouse, parent, etc.)
Who should we thank for
referring you to us or
how did you hear of us?
Emergency contact
telephone number.
I work as a:
 Payment type
Name of school or place of work.
Student
Self pay
Insurance
Work at home
Medicare
(Please have your current insurance
cards and ID available at your
appointment).
Medicaid
Unemployed
Other
Disabled
(Optional)
Retired
Name of Insurance provider:
Subscriber ID/ Group number
(Card # / card date)
* Reason for making office
appointment. (Pain, discomfort
or symptoms where in your body).
*Height
* What have you done for your
medical condition or what tests or
treatment have your received before?
Weight
Do you , or did you, have any of the
following medical conditions.
Thyroid Disorder
Heart Disease
 Sinusitis
Hypertension
Breast Condition
Depression
Bleeding Disorder
 Headaches
Breathing Problems
Sexual difficulties
Bowel problems
Leg Swelling
Seizure
Leg Inflammation
 Constipation
reflux
Skin fold rash
 Anxiety
Diabetes
Muscle or joint pain
Ulcer
Sleep Apnea
Other
High Cholesterol
Family History
Have any of your close relatives,
(parents, siblings, children aunts
uncles, etc) had any of the
following medical conditions?
Stroke
Arthritis
High cholesterol
COPD
Cancer
hypertension
Diabetes
Heart disease
Other:
Current Medications (and
doses if readily available)
Surgeries (types and dates)
Other hospitalizations
(for what and date)
Allergies
If you smoke, how much and
for how long?  If you drink,
how much and for how long?
Describe your present
exercise program or
activity level.
Any difficulties with activities of
daily living? (self-care, walking
to the mailbox, grocery
shopping, climbing stairs, etc)
Do you use any assistive devices?
(cane, walker, wheelchair, scooter,
brace, oxygen, sleep apnea
machine? (For how long).
Hobbies or how you enjoy
spending your free time.
(Optional)
Pets, if any, their
names and breed
Any other health information
which would help us take
better care of you.