WELCOME NEW PATIENT
 
Please fill out  this form, then click the Submit button at the bottom of the page.  The form will be emailed over our secure server to Optimal Health Resources.  We recommend that you print a copy for your records and to take with you when you visit Dr. Yerby.

 
PATIENT PERSONAL INFORMATION
 
First Name: Last Name:
Street Address: Apartment:
City: State:
Zip Code: Birth Date:
Home Telephone: Work Telephone:
Cell Phone: Email Address:
Sex: Male Female Nick Name:
Marital Status: Employment:
Employer Name:
Student:
School Name:    
PATIENT MEDICAL HISTORY
 
Please list any of the conditions below that your relatives
have and select the person or persons relationship to you.
 
Heart Disease: Yes No
Please list relative or relatives with heart disease (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)


High Blood Pressure: Yes No
Please list relative or relatives with high blood pressure (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Diabetes: Yes No
Please list relative or relatives with high blood pressure (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Kidney Problems: Yes No
Please list relative or relatives with kidney problems (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Cancer: Yes No
Please list relative or relatives with cancer (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)
Other Condition or Conditions: Yes No

Describe other condition:
Please list relative or relatives with other problems (Example: Father, Mother, Sibling, Paternal Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather, Uncle, Aunt, Cousin)

 
LIST YOUR CURRENT PHYSICIANS
 
Primary Doctor: Specialty:
Doctor: Specialty:
Doctor: Specialty:

 
Enter the date of your last physical exam and the name of the physician who saw you.
 
Date of Last Exam:
Name of Physician:

 
(Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.
 
Date of Last OB/GYN Exam:
Physician:

 
List any medical conditions you have and how long you've had the condition (first month/year diagnosed)
 
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:
Condition:
Month and year diagnosed:

Have you ever gone to an emergency room for treatment in the last year? Yes No

 
How many times in the past year?
 
Total number of visits:

 
List the reason and when you made each ER visit.
 
Reason for visit:
Date of visit:
Reason for visit:
Date of visit:
Reason for visit:
Date of visit:

 
Have you ever stayed in the hospital overnight during the past year?
 
Overnight in hospital: Yes No
Number of times in past year:

 
List the reason and the date and when you stayed overnight.
 
Reason:
Date of stay:
Reason:
Date of stay:
Reason:
Date of stay:

 
Have you had surgery?     Yes No

 
List the type of surgery or reason for surgery including dates.
 
Reason for surgery:
Date of surgery:
Reason for surgery:
Date of surgery:
Reason for surgery:
Date of surgery:

 
List any allergies you have to food or medications.

 
Have you ever had an anaphylactic reaction
(turning red, overall swelling, difficulty breathing)?   Yes No

Do you smoke? Yes No
Select which products you use, how much, and number of years used.

Cigarettes: Yes No
Cigars: Yes No
Pipes: Yes No
Tobacco Chew: Yes No

How much and number of years used:
 
Do you drink alcohol? Yes No
Beer:
Glasses of wine per day:
Glasses of liquor per day:
 
Do you take any recreational drugs? Yes No
 
Are you taking any prescription drugs or supplements currently? Yes No

 
List drug or supplement, dosage, and how often you take them.
 
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Supplement or Drug Name:
Dosage:
How often:
Please tell me how you would like me to help you:
 
I request an appointment:
We would greatly appreciate if you would fill out the following.

How did you hear about me?