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Patient Information
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Patient Information
Next of Kin & Emergency Contact Information
Medical History
Health/Lifestyle Habits
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Patient Name
*
Patient Name
First Name
First Name
Last Name
Last Name
Gender
*
Male
Female
Patient Date of Birth
*
Patient Email
*
Patient Phone
*
Unit Preference for Patient Details?
*
Imperial
Metric
Please choose the unit preference for entering the patient’s weight and height.
Patient Height (Feet/Inches)
*
4 ft 0 in
4 ft 1 in
4 ft 2 in
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4 ft 10 in
4 ft 11 in
5 ft 0 in
5 ft 1 in
5 ft 2 in
5 ft 3 in
5 ft 4 in
5 ft 5 in
5 ft 6 in
5 ft 7 in
5 ft 8 in
5 ft 9 in
5 ft 10 in
5 ft 11 in
6 ft 0 in
6 ft 1 in
6 ft 2 in
6 ft 3 in
6 ft 4 in
6 ft 5 in
6 ft 6 in
6 ft 7 in
6 ft 8 in
6 ft 9 in
6 ft 10 in
6 ft 11 in
7 ft 0 in
Patient Weight (Pounds)
*
100 lbs
110 lbs
120 lbs
130 lbs
140 lbs
150 lbs
160 lbs
170 lbs
180 lbs
190 lbs
200 lbs
210 lbs
220 lbs
230 lbs
240 lbs
250 lbs
260 lbs
270 lbs
280 lbs
290 lbs
300 lbs
Patient Height (Centimeters)
*
121.92 cm
124.46 cm
127 cm
129.54 cm
132.08 cm
134.62 cm
137.16 cm
139.7 cm
142.24 cm
144.78 cm
147.32 cm
149.86 cm
152.4 cm
121.92 cm
124.46 cm
127 cm
129.54 cm
132.08 cm
134.62 cm
137.16 cm
139.7 cm
142.24 cm
144.78 cm
147.32 cm
149.86 cm
152.4 cm
154.94 cm
157.48 cm
160.02 cm
162.56 cm
165.1 cm
167.64 cm
170.18 cm
172.72 cm
175.26 cm
177.8 cm
180.34 cm
182.88 cm
185.42 cm
187.96 cm
190.5 cm
193.04 cm
195.58 cm
198.12 cm
200.66 cm
203.2 cm
205.74 cm
208.28 cm
210.82 cm
213.36 cm
Patient Weight (Kg)
*
45.36 kg
49.90 kg
54.43 kg
58.97 kg
63.50 kg
68.04 kg
72.57 kg
77.11 kg
81.65 kg
86.18 kg
90.72 kg
95.25 kg
99.79 kg
104.33 kg
108.86 kg
113.40 kg
117.93 kg
122.47 kg
127.01 kg
131.54 kg
136.08 kg
Reason For Seeing The Doctor?
*
Please enter the symptoms you are experincing.
Date
*
Do You Have Health Insurance
*
Yes
No
Select Your Health Insurance Provider
*
UnitedHealth Group
Elevance Health Inc. (formerly Anthem)
Centene Corp.
Kaiser Foundation (Kaiser Permanente)
Humana
CVS Health (including Aetna Health)
Health Care Services Corporation (HCSC)
Cigna Health
Molina Healthcare Inc.
GuideWell (including Florida Blue)
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Michigan
Independence Health Group
Wellcare Health Plans
Highmark Group
CareSource
Medica Health Plans
UPMC Health Plan
Excellus Health Plan Inc.
Amerigroup
MetroPlus Health Plan
Fidelis Care
Priority Health
Independence Blue Cross
Tufts Health Plan
Community Health Choice
Geisinger Health Plan
Oscar Health
HealthPartners
Harvard Pilgrim Health Care
Horizon Blue Cross Blue Shield of New Jersey
Molina Healthcare of California
MVP Health Care
Bright HealthCare
Capital District Physicians’ Health Plan (CDPHP)
Wellmark Blue Cross Blue Shield
AllWays Health Partners
Inter Valley Health Plan
Group Health Cooperative of Eau Claire
SummaCare
SelectHealth
Blue Shield of California
Neighborhood Health Plan of Rhode Island
Security Health Plan of Wisconsin
AvMed Health Plans
Fallon Community Health Plan
ConnectiCare
Presbyterian Healthcare Services
Rocky Mountain Health Plans
Scott and White Health Plan
Other
Select Your Health Insurance Provider
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