Elementor #1294 – Fairfield Family Physicians

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Use this form to update patient information and for new patient

Your Name *

First

Middle

Last

Date of Birth *

Social Security Number *

Email *

Your Phone Number *

Street *

City *

State *

Zip Code *

Gender *

Employment Status *

Employer

Primary Care Provider

Emergency Contact *

First

Last

Relationship *

Emergency Contact Phone *

Primary Insurance Company

Phone Number

Group Number

ID Number

Policy Holder Name

First

Last

Policy Holder Date of Birth

Policy Holder Social Security Number

Relationship to the Insured

Policy Holder's Street

Policy Holder's City

Policy Holder's State

Policy Holder's Zip Code

Have you had any of the following symptoms

Weight loss/gain
Decreased appetite
Sleep disturbances
Heart palpitations
High blood pressure
Chest pains/tightness
Shortness of breath
Frequent headaches
Sleep Apnea
Motor/vocal tics (twitches)
Urination issues
Rigid/inflexible/joint pain
Anxious
Depression
Paranoid
Racing thoughts
Obsessive compulsive behavior
Over sensitive/sensory issues (tastse/sound/noise)
Agression/Frequent anger
Substance abuse
None of the above

Select all that apply

List any medical allergies (one per line)

List any current medication (one per line)

Surgeries/Hospitalizations History

If you had surgeries and/or were hospitalized, please list approximate date (month/year).

Medical History

Diabetes
Hypertension
Hypothyroidism
Kidney/Renal
Headaches/Migranes
Asthma
COPD
CHF
ADHD
Panic attacks
Schizophrenia/psychosis
Anxiety
Bipolar disorder
Depression
Other

Select all that apply.

Explain if you select 'Other'

Sleeping History

Trouble falling asleep
Trouble staying asleep
Sleep walking
Sleep talking
Nightmares/terrors
Gone 24 hours without sleep
Do you frequently sleep after work/school?
Do you frequently feel tired or fall asleep during the day?

Select all that apply.

Number of children *

What is your highest level of education? *

Are you currently in college/graduate school? *

What kind of work do you do? *

Do you exercise regularly? *

Generally, how would you describe your stress level?

What is your driving history?

Violations
Accidents
License suspended or revoked

Select all that apply

How many caffeinated beverages do you normally consume per day?

None
1 to 2
3 to 5
6 or more

Do you use alcohol? *

If yes, how often do you consume alcohol?

Do you use tobacco or vape? *

Do you use marijuana? *

Have you used, or are you currently using other illicit drugs? *

Do you participate in any type of rehab program, or substance abuse counseling? *

Name