First Choice Walk-In Care: Information For Your Provider Form
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1First Choice Walk-In Care
Information For Your Provider
PLEASE PRINT
Patient Last Name
Patient First Name
Middle Initial
Sex
Who is your personal physician?
REASON YOU NEED TO BE SEEN TODAY? (symptoms)
□Yes □No
Is this related to a work injury or motor vehicle accident?
List all your medications: (include vitamins, injections, herbs, nasal sprays, oral sprays, patches, non-prescription drugs).
List dosages if you know them.
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Not taking any medications
Medication: _________________________________________ Reason: _______________________________________________
Medication: _________________________________________ Reason: _______________________________________________
Medication: _________________________________________ Reason: _______________________________________________
Medication: _________________________________________ Reason: _______________________________________________
Medication: _________________________________________ Reason: _______________________________________________
What pharmacy would you like your prescription faxed to today? _________________________________________________
List pharmacy name, street and city
Are you allergic to any drugs? If so, list them and the reaction which occurred.
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Do you smoke?
Yes
No
Do you drink?
Yes
No
Check the appropriate surgeries you have had and what year they were performed:
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Adenoids
Tonsils
Sinus
Eye
Heart/What type?___________________
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Appendix
Colon
Uterus or Ovaries
Bladder
Tubal
Vasectomy
Other _________________
Do you have or ever had any of the following conditions? Please check all that apply.
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Asthma
Diabetes
Cholesterol
Chronic Pain/From?__________
Thyroid
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Heart Disease
High Blood Pressure
COPD or lung disease
Tuberculosis?
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Reflux/Ulcer
Liver disease
Kidney disease
Cancer/What type?____________
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Depression
Anxiety
Bipolar Disorder
None listed above
Other __________________
Family History: Have your parents, grandparents, brothers or sisters been treated for any of the following?
Check
all that apply.
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Diabetes
Thyroid
High Blood Pressure
Heart Disease
Stroke
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Cancer/What type?___________________________
Other __________________________
None of the above
List phone number we can call about visit & leave a voice message at: _________________________
Doctor Initials
Is there a cell phone number you can be reached at? _________________________
PATIENT or
GUARDIAN Signature ____________________________________________ Date:
Time:
Relationship to Patient: _________________________________________________
OFFICE USE ONLY:
Consent to treat obtained from: Name: __________________________ Relation to patient: ___________PH: _________________
Vitals: Wt:_____ T: ______ BP: _____ Pulse:_____ RR:_____ Pulse ox:______ Vision: Rt 20/___ Lt 20/___
LMP:_______ Contraception:_______
Tob: □Yes □No
ETOH: □Yes □No
04031611 NS (11/07)
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Parent category: Business