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After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
---------- Date of Birth ----------
------- Fecha de nacimiento -------
------- Fecha de nacimiento -------
------- Fecha de Nacimiento -------
First Name
Nombre
Nombre
Nombre
Last Name
Apellido
Apellido
Apellido
Month
Mes
Mes
Mes
Day
Día
Día
Día
Year
Año
Año
Año
Gender
Género
Género
Género
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Please mark only the symptoms you
currently
are experiencing.
Por favor marque todos los síntomas que actualmente esta sintiendo.
Mark all that apply - if no symptoms, please mark
None
.
Marque todos los que aplican. Si no hay ningun síntoma, marque
Ninguno
.
Do not print these forms!
¡No imprima estas formas!
General
chills
escalofríos
unintentional weight gain
sobre peso involuntario
fever
fiebre
unintentional weight loss
pérdida de peso involuntario
None
Ninguno
Skin
Piel
brittle nails
uñas frágiles
new lesion(s)
nuevas lesiones
changes in nails
cambio en las uñas
skin color changes
cambio de color en la piel
None
Ninguno
Respiratory
Respiración
difficulty breathing on exertion
dificultad de respiración al esforzarse
cough
tos
shortness of breath
pérdida de respiración
skin color changes
cambio de color en la piel
None
Ninguno
Cardiovascular
chest pain
dolor en el pecho
None
Ninguno
Ninguno
Musculoskeletal
Musculoesquelético
atrophy
atrofia
joint stiffness
coyunturas tiesas
decreased range of motion
debilidad al moverse
joint swelling
coyunturas inflamadas
joint pain
dolor en las coyunturas
muscle swelling
inflamación de músculo
joint redness
coyunturas rojas
muscle weakness
músculos debiles
None
Ninguno
Neurologic
Neurológico
seizures
convulsiones
burning
ardor
stroke
embolia
focal problems
problemas para enfocarse
swelling
inflamación
numbness
entumido
tingling
hormigueo
None
Ninguno
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 165
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.