Patient Information Sheet
1. Personal Information:
Full Name: Lyda Fadel
Date of Birth: January 1, 2050
Gender: Female
Address: Miami, FL 33101
Contact Information: 222 555 7777, lyda@you.mail
Emergency Contact Name: Conan Fadel
Emergency Contact Number: 222 555 7777
2. Medical History:
Field | Details |
|---|
Do you have any chronic conditions (e.g., diabetes, hypertension)? | Hypertension |
Have you had any major surgeries or hospitalizations? | Appendectomy (2060) |
Are you currently taking any medications? | Lisinopril 10mg, Vitamin D supplements |
Do you have any allergies (medications, food, environmental)? | Penicillin and peanuts |
Do you have a family history of any medical conditions? | Family history of diabetes and hypertension |
3. Lifestyle and Habits:
Do you smoke? | Do you drink alcohol? | Do you exercise regularly? |
|---|
If yes, how many cigarettes per day?: N/A | If yes, how many drinks per week?: 3 | If yes, what type of exercise and how often?: Running, 3 times a week |
4. Insurance Information:
Insurance Provider: BlueLeaf
Policy Number: 123456789
Group Number (if applicable): 987654
Primary Insured Name (if different): Conan Fadel
Relationship to Primary Insured: Spouse
5. Consent and Signature:
I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that providing false information may affect my treatment.
Lyda Fadel: _____________________
Date Signed: January 5, 2050
6. For Clinic Use Only:
Patient ID: 2080-001
Date of First Visit: January 6, 2080
Physician/Provider Name: Dr. [YOUR NAME], [YOUR COMPANY NAME]
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