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I693 IMMIGRATION PHYSICAL
Immigration Packet
Required Vaccinations
Frequently Asked Questions
NEW PATIENT FORM
PATIENT First name
PATIENT Last name
PATIENT Date of Birth
Month
Day
Year
PATIENT Email
PATIENT Phone #
PATIENT Gender
Male
Female
Prefer Not To Say
PATIENT Address
SS#
PATIENT Marital Status
Married
Divorced
Widowed
Single
EMERGENCY CONTACT NAME
EMERGENCY CONTACT NUMBER
RELATIONSHIP TO PATIENT
Reason for Visit
New Patient
Immigration
Pre- Employment
Other
INTERPRETER NAME AND NUMBER ( IMMIGRATION ONLY)
Are you under the care of a primary physician?
Yes
No
If so, what is the name of the office, contact number and doctor you are seeing?
Do you currently see any other specialists?
Yes
No
If so, what is the name of the office, contact number, their specialty and doctor you are seeing?
Are you currently taking any medications or herbal supplements? If so, please list the name, dosage, and the frequency in which you take it below.
Submit
Do you have any food or environmental allergies?
Are you allergic to, or had a reaction to the following? (Please select all that apply)
Penicillin
Sulfites
Amoxicillin
Sulfa Drugs
Aspirin
Latex
Local Anesthetic
Codeine or other narcotics
Sodium Pentothal/Valium/ Other Tranquilizers
Soy
Eggs/Yolk
Other Allergies Unlisted Here
Medicinal Allergies Unlisted Above and Reaction:
Do You Smoke?
Yes
No
How many packs per day and how many years have you been smoking?
Do you drink alcohol?
Yes
No
How many drinks per week do you consume?
Recreational Drug Use?
Yes
No
What type and how often do you consume them?
Do you exercise regularly?
Yes
No
What type and how often do you exercise?
Are you currently sexually active?
Yes
No
If you are, how many sexual partners have you had in the last year?
Do you have sex with men, women or both?
Do you use protection?
Yes
No
Have you ever had an STI?
Submit
Women Only: Antibiotics may alter the effectiveness of birth control pills. Have you been on any in the last 3 months?
Is there a possibility of pregnancy?
Yes
No
Are you nursing?
Yes
No
Are you taking birth control?
Yes
No
Expected Delivery Date if Applicable?
When was your last menstrual period?
Do you have, or have had, any of the following diseases, medical conditions, or procedures? Click all that apply.
A History of Drug Abuse
A History of Alcohol Abuse
Abnormal Bleeding
Anemia
Are You on a Diet?
Are You on Dialysis?
Arthritis/Joint Pain
Asthma
Bleeding Tendency
Blood Disorder
Blood Transfusion
Bruise Easily
Cancer/Radiation/Chemo
Cardiac Pacemaker
Chest Pain/ Angina
Chronic Fatigue/Night Sweat
Contact Lenses
Contagious Diseases
Convulsions/Epilepsy
Damaged Heart Valves
Delay In Healing
Diabetes
Emphysema
Eye Disease/Galucoma
Fainting Spells
Gallbladder Trouble
GI Trouble/IBS/Colitis
Hay Fever/Sinus Problems
Heart Attack
Heart Murmur
Heart Surgery
Hepatitis
High Blood Pressure
Headache
Infectious Mononucleosis
Irregular Heart Beat
Jaundice/Liver Disease
Joint Replacement
Kidney Trouble
Low Blood Pressure
Anxiety/Depression/Mental Health Issues
Mitral Valve Prolapse
Osteonecrosis
Osteoporosis/Osteopenia
Pneumonia/Bronchitis
Problems With Immune System
Prosthetic Implant
Respiratory Problems
Rheumatic Fever
STI's
Sleep Apnea/CPAP
Snoring
Stomach Ulcers
Stroke
Swollen Ankles
Thyroid Trouble
Tuberculosis
Tumor or Growths
Trouble Climbing 1-2 Flights of Stairs
Other
Please list any past surgeries, procedures, or overnight hospital stays. Include as much detail as possible.
Submit
IMMIGRATION PHYSICALS ONLY
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