Patient Intake Form (#5) Paso 1Paso 2ResumenFirst NameLast NamePatient AgePatient Gender- Select -MaleFemaleOthersPhone no.PreviousNextWith whome do you live?Marital Status Married Unmarried otherMarital status(other)Section BreakSome description about this sectionOccupationRetired? Yes NoDate of retirementDisability ? Yes NoDate of disabilityWho is your primary care doctor: Where is your primary care doctor located ? Phone Number of primary care doctor:allergic to any medications Yes Noallergic to any medicationsPreviousNextDo you smoke? Yes NoHow many years did you smoke?If you quit, when did you stop?Do you drink alcohol? Personal opinion Previous Submit Form
