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470-205-5136

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New Patient Intake Form

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New Patient Intake Form

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Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Sex
- Male
- Female
Employer / Occupation
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact
First Last
Contact Phone
Relationship to you

Health History
Have you had or do you currently...
(please check all that apply)
- High blood pressure
- Chest pain/angina
- Heart attack(s)
- Irregular heart beat
- Cardiac pacemaker
- Are you on dialysis?
- Stomach ulcers
- History of breast cancer
- History of uterine cancer
- History of ovarian cancer
- History of prostate cancer
- Reduced sex drive
- Blood disorder such as anemia
- Bruise easily
- Gallbladder trouble
- Fainting spells
- Thyroid trouble
- Diabetes
- Low blood sugar
- Swollen ankles, arthritis, or joint disease
- Sleep apnea
- Insomnia or poor sleep quality
Are you currently taking…
(please check all that apply)
- Blood thinners
- Sleep-inducing medications
- Cortisone
- Medications for acid reflux or GERD
- Prescription appetite suppressants (Adipex, phentermine, etc.)
- Thyroid meds
- Antibiotics
- Blood pressure meds
- Aspirin
- Ibuprofen or Tylenol
- Antihistamines/decongestants
- Antidepressants or anxiety medications
- Muscle relaxants or tranquilizers
- Insulin or diabetic meds

Health History (continued)
Are you allergic to or have you had a reaction to...
(please check all that apply)
- Local anesthetics
- Penicillin
- Other Antibiotics
- Aspirin
- Codeine or other narcotics
- Any other drug allergies?
- Latex
Women
Could you possibly be pregnant?
- Yes
- No
Are you currently on birth control?
- Yes
- No
Date of your last menstrual period:
Date of your last pap smear:
Date of your last mammogram:
Men
Date of your last prostate exam:
Date of your last PSA test:
Current Health
Current Height
Current Weight
Do you consider yourself in good health?
- Yes
- No
Any change in your health in the past year?
- Yes
- No
Are you under the care of a physician?
- Yes
- No
Have you ever been hospitalized? If so, please list dates and reasons for your Hospitalization:

Current Medication
List All Current Medications
Current Meds/Supplements, Strength Dose, Comments
Compliance & Agreement
Certify that I have read and understand*
I certify that I have read and understand the questions in these forms; I acknowledge that I will have the opportunity to discuss my health history with my doctor. I will not hold my doctor or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of these forms.
I agree
Consent to antibody testing*
In the event of an accidental exposure to blood or other bodily fluids through needle stick, cut, mucous membrane contact, or the like, the undersigned consents to appropriate tests for the presence of Hepatitis B & C and HIV, which is the virus believed to cause AIDS. The patient will be informed of any positive results, and all such results will be treated as confidential by Chimera Medical Services. There is no charge to the patient.
I agree and understand
Signature
Name
This field is for validation purposes and should be left unchanged.

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Body Symmetry MD

Norcross / Peachtree Corners

6063 Peachtree Parkway Suite 102A Norcross, GA 30092

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Sandy Springs / Atlanta

275 Carpenter Drive Suite 102 Atlanta, GA 30328

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Roswell / Alpharetta

202 Bombay Lane Roswell, GA 30076

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