Form – Patient Health History Form 2 First name(Required) Nickname Last name(Required) Middle name Suffix Home Email Work Email By providing my email address, I authorize my doctor to contact me via the email address(es) provided.Which email address would you like us to use to communicate with you? Home Work Contact Method Primary Phone Secondary Phone Mobile Phone Home Email Work Email (check one)Date of Birth MM slash DD slash YYYY Age Gender Female Male Unspecified Marital Status Single Married Other (check one)SSN Employment Status Employed FT Student PT Student Other Retired Self Employed (check one)Race White Asian Japanese Samoan Black/African American Asian Indian Korean Guamanian or Chamorro Hispanic Chinese Vietnamese American Indian/Alaskan Native Filipino Native Hawaiian or other Pacific Island I choose not to specify Other (check one) Other Multi-Racial Yes No Unknown (check one)Ethnicity Hispanic or Latino Not Hispanic or Latino I choose not to specify (check one)Preferred Language (check one) English Tagalog Arabic Persian Spanish Vietnamese Portuguese Urdu American Sign Language Italian Japanese Gujarati Chinese Korean French Creole Armenian French Russian Greek German Polish Hindi I choose not to specify (check one)Verification Question (choose only one question by circling the question, then give the answer to that question)What is the name of your favorite pet? In what city were you born?What high school did you attend?What is your favorite movie?What is your mother’s maiden name? On what street did you grow up?What was the make of your first car? When is your anniversary?Verification Answer to the Chosen question: Answers must be at least 6 characters.Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoke If yes, how often do you smoke: Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? 0 (No interest) 1 2 3 4 5 6 7 8 9 10 (Very interested) Current medications, including frequency and dosage if known. If there are no current medications, check here:List any known allergies you have had to any medications. If no allergies are known, check here:Briefly list your main health problemsHas any doctor diagnosed you with Hypertension presently? Yes No If yes, describe: Has any doctor diagnosed you with Diabetes presently? Yes No If yes, what kind? Type I Type II If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%? Yes No Not Sure If yes, other comments regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No CAPTCHANameThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).