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. We recommend that you print a copy for your records and to take it with you when you visit Dr. Yerby. Please call Dr. Yerby within 24 hours of filling out this form to discuss setting up your appointment.

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:	Select Here Single Married Divorced Separated Widowed	Employment:	Select Here Full Time Part Time Unemployed Retired
Employer Name:
Student:	Select Here Full Time Part Time N/A
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:

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:	Select Here Daily Multiple times per day Weekly Several times per week Monthly Several times per month

Supplement or Drug Name:
Dosage:
How often:	Select Here Daily Multiple times per day Weekly Several times per week Monthly Several times per month

Supplement or Drug Name:
Dosage:
How often:	Select Here Daily Multiple times per day Weekly Several times per week Monthly Several times per month
Supplement or Drug Name:
Dosage:
How often:	Select Here Daily Multiple times per day Weekly Several times per week Monthly Several times per month

Please tell us how you would like Dr.Yerby to help you (required):

What is your insurance company, for situations in which we may be able to use it?

I request an appointment: Select Here Clinic Visit Phone Consult
We would greatly appreciate if you would fill out the following. How did you hear about Dr. Yerby?
Select Here AANP Website Local Paper Company Program Friend Referral Doctor Referral Yellow Pages Internet Search T. Shepherd Other
How carefully have you read Dr. Yerby's website?
Select Here Completely Somewhat Slightly Not at all
Please call Dr. Yerby within 24 hours of submitting this form to set up your appointment: 919-704-6298