Patient Intake Form (#5)Paso 1Paso 2ResumenFirst Name Last Name Patient Age Patient Gender - Select -MaleFemaleOthersPhone no. PreviousNextWith whome do you live? Marital Status Married Unmarried otherMarital status(other) Section BreakSome description about this sectionOccupation Retired? Yes NoDate of retirement Disability ? Yes NoDate of disability Who 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 medications PreviousNextDo 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
