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Dr. ASHWIN PATEL, MD
INTERNAL MEDICINE
2315 W. Bethany Home Rd,
Phoenix, AZ 85015
602-249-2848
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Name (Last,First):
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EMERGENCY CONTACT
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How Did You Hear About Us?
PRIMARY INSURANCE
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SECONDARY INSURANCE
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GENERAL MEDICAL HISTORY
ALLERGIES
MEDICATIONS
HOSPITALIZATIONS
TOBACCO ASSESSMENT
Never Smoked
Tobacco User
#packs
years
Date quit smoking
SOCIAL HISTORY
Alcohol Use
Drinks Per Day
Non Drinker
Caffeine Use
Cups Per Day
No Caffeine
SURGERIES/PROCEDURE
Appendectomy
Gall Bladder
Hysterectomy
Breast Lumpectomy
Heart Surgery
Laproscopy
Endometrial Ablation
Hernia
Mastectomy
Cataract Surgery
Hemorrhoids
Other Surgical/Procedure History
YOUR GENERAL MEDIAL HISTORY (Mark yes if applicable)
Yes
No
Alcoholism
Yes
No
Allergies/Hay Fever
Yes
No
Anemia
Yes
No
Anxiety
Yes
No
Asthma
Yes
No
Atrial Fibrillation
Yes
No
Blood Transfusions
Yes
No
CAD
Yes
No
Cancer
Yes
No
Cardiac Pacemaker
Yes
No
Cardiovascular Disease
Yes
No
CHF
Yes
No
Cirrhosis
Yes
No
Colitis
Yes
No
COPD
Yes
No
CRF
Yes
No
Crohn's Disease
Yes
No
CVA
Yes
No
DVT
Yes
No
Depression
Yes
No
Diabetes Type 1
Yes
No
Diabetes Type 2
Yes
No
Epilepsy
Yes
No
Fracture
Yes
No
Gastric Ulcer
Yes
No
Gastro Disease
Yes
No
GERD
Yes
No
Gestational Diabetes
Yes
No
Glaucoma
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
High Cholesterol
Yes
No
Hyperlipidemia
Yes
No
Hypertension
Yes
No
Hyperthyroidism
Yes
No
Insulin Pump
Yes
No
Joint Pain
Yes
No
Kidney Functions
Yes
No
Kidney Stone
Yes
No
Migraine
Yes
No
Multiple Sclerosis
Yes
No
Obesity
Yes
No
Old MI
Yes
No
Osteoarthritis
Yes
No
Osteoporosis
Yes
No
Pneumonia
Yes
No
Prog Neuro Disease
Yes
No
Pulmonary Disease
Yes
No
Rheumatic Fever
Yes
No
Rheumatoid Arthritis
Yes
No
STD
Yes
No
Terminal Illness
Yes
No
Thyroid Disease
Yes
No
TIA
Yes
No
Tuberculosis
Yes
No
Valvar Problems
MOTHER GENERAL HISTORY (Mark yes if applicable)
Living
Deceased
In Good Health
Yes
No
Yes
No
Alcoholism
Yes
No
Anemia
Yes
No
Anxiety
Yes
No
Asthma
Yes
No
Birth Defects
Yes
No
CAD
Yes
No
Cardiovascular Disease
Yes
No
CHF
Yes
No
Cancer
Yes
No
Congenital Anomaly
Yes
No
COPD
Yes
No
Crohn's Disease
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
GERD
Yes
No
High Cholesterol
Yes
No
Hyperlipidemia
Yes
No
Hypertension
Yes
No
Hypothyroidism
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Multiple Births
Yes
No
Osteoarthritis
Yes
No
Osteoporosis
Yes
No
Pulmonary Disease
Yes
No
Stroke
Other Conditions
FATHER GENERAL HISTORY (Mark yes if applicable)
Living
Deceased
In Good Health
Yes
No
Yes
No
Alcoholism
Yes
No
Anemia
Yes
No
Anxiety
Yes
No
Asthma
Yes
No
Birth Defects
Yes
No
CAD
Yes
No
Cardiovascular Disease
Yes
No
CHF
Yes
No
Cancer
Yes
No
Congenital Anomaly
Yes
No
COPD
Yes
No
Crohn's Disease
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
GERD
Yes
No
High Cholesterol
Yes
No
Hyperlipidemia
Yes
No
Hypertension
Yes
No
Hypothyroidism
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Multiple Births
Yes
No
Osteoarthritis
Yes
No
Osteoporosis
Yes
No
Pulmonary Disease
Yes
No
Stroke
Other Conditions
CONSENT TO TREAT
My signature (printer full name) below means that I agree and consent to allow the doctor to examine and provide medical treatment to me and to use and disclose my protected health information to carry out treatment, payment, and healthcare operations.
Patient Full Name (last, middle, first)
Date Of Birth
Date: 02-16-25
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