Free Patient Information Sheet Template
Patient Information Sheet
1. Personal Information:
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Full Name: John Doe
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Date of Birth: January 1, 2000
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Gender: Male
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Address: 123 Health Street, Wellness City, HC 12345
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Phone Number: (123) 456-7890
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Email Address: johndoe@example.com
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Emergency Contact Name: Jane Doe
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Emergency Contact Phone: (098) 765-4321
2. Medical History:
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Do you have any chronic conditions (e.g., diabetes, hypertension)?
Hypertension
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Have you had any major surgeries or hospitalizations? If yes, please specify:
Appendectomy (2040)
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Are you currently taking any medications? If yes, list them:
Lisinopril 10mg, Vitamin D supplements
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Do you have any allergies (medications, food, environmental)?
Penicillin, peanuts
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Do you have a family history of any medical conditions? If yes, please describe:
family history of diabetes and hypertension
3. Lifestyle and Habits:
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Do you smoke?
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Yes
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No
If yes, how many cigarettes per day?: N/A
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Do you drink alcohol?
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Yes
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No
If yes, how many drinks per week?: 3
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Do you exercise regularly?
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Yes
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No
If yes, what type of exercise and how often?: Running, 3 times a week
4. Insurance Information:
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Insurance Provider: HealthPlus
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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): Jane Doe
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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.
John Doe
Date: January 5, 2050
6. For Clinic Use Only:
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Patient ID: 2050-001
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Date of First Visit: January 6, 2050
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Physician/Provider Name: Dr. [Your Name]
Instructions for Patients:
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Please complete this form before your first appointment.
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Bring any relevant medical documents, test results, or imaging.
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Notify us immediately of any changes to your contact or medical information.
