Appointment FormFill-up The Form to Get Our Medical ServicesGenderMaleFemaleOtherMarital StatusSingleMarriedWHAT SYMPTOMS ARE YOU HAVING TODAY? IF INJURED, PLEASE EXPLAIN HOW THE INJURY OCCURRED, WHEN AND EXACTLY WHAT BODY PART WAS INJURED.FEMALES ONLY: ARE YOU PREGNANT?YesNoUnsureHAVE YOU HAD ANY SURGERIES IN THE PAST?YesNoARE YOU ALERGIC TO ANY DRUGS, FOODS, INSECTS ?YesNoDO YOU HAVE ANY ONGOING MEDICAL PROBLEMS?YesNoMEDICATION CURRENTLY TAKINYesNoPLEASE SELECT IF YOU HAVE EVER HAD ANY OF THE FOLLOWING OR SELECT NONENoneAIDS/HIVAsthmaArthritisBlood Pressure (high or low)High CholesterolKidney DiseaseLung DiseaseEar InfectionsCOPD/EmphysemaCancerBlood ClotsMigraines/HeadacheStroke/TiaUrination Problems/infectionsBronchitisDepression/AnxietDiabeticHepatitis/Liver DiseaseRheumatic feverThyroid DiseaseHeart Disease/AttackDO YOU SMOKE?YesNoCHEW TOBACCO?YesNoRECREATIONAL DRUGS?YesNoDO YOU DRINK ALCOHOL?YesNoI DO NOT AUTHORIZE R.U.C TO DISCLOSE ANY INFORMATION.I herby authorize R.U.C to use and disclose health information to the following person:By submitting this form above, I agree to Rosenberg Urgent Care’s Privacy and Health Insurance Claim Processing Policies. I agree to sign this form by typing in my name belowFirst NameLast NameBook NowMaleFemaleOtherSingleMarriedWhat symptoms are you having today? If injured, please explain how the injury occurred, when and exactly what body part was injured.Females Only: Last Menstrual PeriodAre you pregnant?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoUnsureHAVE YOU HAD ANY SURGERIES IN THE PAST?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoARE YOU ALLERGIC TO ANY MEDICATIONS?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoDO YOU HAVE ANY ONGOING MEDICAL PROBLEMS?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoDO YOU SMOKE?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoCHEW TOBACCO?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoDO YOU DRINK ALCOHOL?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoRECREATIONAL DRUGS?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoEMERGENCY CONTACT:I DO NOT AUTHORIZE SWUCFP TO DISCLOSE ANY INFORMATION.I herby authorize SWUCFP to use and disclose health information to the following person:Please select if you have ever had any of the following or select NONEHAVE YOU HAD ANY SURGERIES IN THE PAST?AIDS/HIVAsthmaArthritisBlood Pressure (high or low) High Cholesterol Kidney DiseaseLung DiseaseHAVE YOU HAD ANY SURGERIES IN THE PAST?Ear InfectionsCOPD/EmphysemaCancerBlood ClotsMigraines/HeadacheStroke/Tia Urination Problems/infectionsHAVE YOU HAD ANY SURGERIES IN THE PAST?BronchitisDepression/AnxietDiabeticHepatitis/Liver DiseaseRheumatic feverThyroid DiseaseHeart Disease/AttackList of medication you are currently taking vitamins, supplements, and over the counter meds (If yes fill -If no medication tick NONEMEDICATIONHAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoHAVE YOU HAD ANY SURGERIES IN THE PAST?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoHAVE YOU HAD ANY SURGERIES IN THE PAST?HAVE YOU HAD ANY SURGERIES IN THE PAST?yesNoBook Now
