· 2016-10-12 · do you have or have you had a disease, condition, problem, or surgery not...
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Name ____________________________________________ Address ______________________________________________________________
Email _____________________________________________ City ____________________________ State ____________ Zip _____________
Home# ____________________ Work# ____________________ Cell# ____________________
1. Are you currently, or have you been under the care of a physician or hospitalized in the past 2 years? .................................................. YES NO
If so, for what reason? ___________________________________________________________________________________________________
Physician’s Name _______________________________________________________ Telephone ____________________________________
2. Have you taken any medication or drugs in the past 2 years? ................................................................................................................... YES NO
3. Are you now taking any medications, drugs, or pills (including birth control, aspirin, herbal medicine, or dietary supplements, etc.)? ...... YES NO
If yes, please list: _______________________________________________________________________________________________________
4. Are you aware of being allergic to or have you ever reacted adversely to any medication or substance? ................................................. YES NO
If yes, please list: _______________________________________________________________________________________________________
5. Have you ever had an allergic reaction to latex? ........................................................................................................................................ YES NO
6. Have you ever taken prescription medication for weight reduction (diet pills)? please list: ___________________________________ YES NO
7. Have you ever taken Fosamax, Actonel, Boniva, Didronel, Skelid or any other medication for osteoporosis or other bone conditions? ... YES NO
8. Indicate which of the following you have had or have at present.
9. Do you have or have you had a disease, condition, problem, or surgery not listed? please list: _______________________________ YES NO
10. Do you smoke or use tobacco? ................................................................................................................................................................... YES NO
If female, please answer the following:
Are you taking birth control pills? .................................. YES NO Are you nursing? ................................................................ YES NO
Are you pregnant? ......................................................... YES NO If yes, what month _______________________________
Patient Survey
Date:___________________________
We are always working toward providing the best possible patient care. Periodically, we send out a survey to measure what kind of job we are doing and would like to hear back from you.
NAME:____________________________________________________
E-MAIL ADDRESS:________________________________________Please print e-mail address clearly
Appointment Reminders
Our office wants to communicate with you the way you prefer. How do you want to receive appointment reminders? Please check all that you prefer.
☼ E-MAIL ADDRESS:_____________________________________Please print e-mail address clearly
☼ Text __________________________________________________ Preferred cell phone #
☼ Telephone – please check one of the following:
☼ Personalize phone call
☼ Automated phone call
PLEASE NOTE: When you receive an automated phone call from our office please listen to the prompts at the end of the message and CONFIRM the appointment by pressing the number 1 on your phone.
1-6-15 ptsurveyIV
pressing the number 1 on your phone.
Date:______________________________________________________
NAME:_____________________________________________________
Over the last few months we have conducted a survey and have found that our patients prefer to hear from us via email or text rather than calling.
Our office wants to communicate with you the way you prefer.
Please check your preference.
ʏ���(-MAIL ADDRESS:_____________________________________ Please print e-mail address clearly
ʏ���7H[W���BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Preferred cell phone #
ʏ���7HOHSKRQH Please check one of the following:
ʏ�Personalized phone call ʏ�Automated phone call 11-15-12 ptsurveyIII