Patient Information Sheet

1. Personal Information:

Full Name: Lyda Fadel
Date of Birth: January 1, 2050
Gender: Female
Address: Miami, FL 33101
Contact Information: 222 555 7777, lyda@you.mail
Emergency Contact Name: Conan Fadel
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?
Yes No If yes, how many cigarettes per day?: N/A	Yes No If yes, how many drinks per week?: 3	Yes No If yes, what type of exercise and how often?: Running, 3 times a week

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:

Insurance Provider: BlueLeaf
Policy Number: 123456789
Group Number (if applicable): 987654
Primary Insured Name (if different): Conan Fadel
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