Free Patient Information Sheet Template
Patient Information Sheet
1. Personal Information:
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Full Name: Lyda Fadel
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Date of Birth: January 1, 2050
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Gender: Female
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Address: Miami, FL 33101
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Contact Information: 222 555 7777, lyda@you.mail
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Emergency Contact Name: Conan Fadel
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Emergency Contact Number: 222 555 7777
2. Medical History:
|
Field |
Details |
|---|---|
|
Do you have any chronic conditions (e.g., diabetes, hypertension)? |
Hypertension |
|
Have you had any major surgeries or hospitalizations? |
Appendectomy (2060) |
|
Are you currently taking any medications? |
Lisinopril 10mg, Vitamin D supplements |
|
Do you have any allergies (medications, food, environmental)? |
Penicillin and peanuts |
|
Do you have a family history of any medical conditions? |
Family history of diabetes and hypertension |
3. Lifestyle and Habits:
|
Do you smoke? |
Do you drink alcohol? |
Do you exercise regularly? |
|---|---|---|
If yes, how many cigarettes per day?: N/A |
If yes, how many drinks per week?: 3 |
If yes, what type of exercise and how often?: Running, 3 times a week |
4. Insurance Information:
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Insurance Provider: BlueLeaf
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Policy Number: 123456789
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Group Number (if applicable): 987654
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Primary Insured Name (if different): Conan Fadel
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Relationship to Primary Insured: Spouse
5. Consent and Signature:
I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that providing false information may affect my treatment.
Lyda Fadel: _____________________
Date Signed: January 5, 2050
6. For Clinic Use Only:
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Patient ID: 2080-001
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Date of First Visit: January 6, 2080
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Physician/Provider Name: Dr. [YOUR NAME], [YOUR COMPANY NAME]
