Patient Medical History and Intake Form

Complete our form with your medical history for personalized care. Thank you!

Want a physical copy? Feel free to access here.

Scroll down to fill out electronically.

Name*

DOB*

Age*

Address*

Phone*

E-mail*

Reason for visit*

Emergency Contact*

Please briefly describe why you are seeking medical care?*

Allergies (Medications, foods, etc)

Current Medications (Please include OTC & supplements)

Please check any conditions that apply to you: METABOLIC/ ENDOCRINE/ AUTOIMMUNE

Hyper/Hypo Thyroid

Rheumatoid Arthritis

Diabetes Type I Type II

Hx of DKA

Lupus

Date of last Seizure

Please check any conditions that apply to you: HEMATOLOGY

Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)

MTHFR

G6PD Deficiency

Hemophilia

Thrombosis (including DVT)

Please check any conditions that apply to you: MUSCULOSKELETAL

Back Pain

Degenerative Joint Disease

Carpal Tunnel Disorder

Degenerative Disk Disease

Fibromyalgia

Please check any conditions that apply to you: PSYCHOLOGICAL

Depression

Anxiety or Panic Attacks

Suicidal Ideations

CANCER: Location of Cancer

Please check any conditions that apply to you: CANCER

Chemotherapy

Radiation

Please check any conditions that apply to you: WOMEN (non-menopausal) Last Menstrual Period?

Please check any conditions that apply to you: WOMEN (non-menopausal) Any chance that you are pregnant?

Please check any conditions that apply to you: WOMEN (non-menopausal) Are you currently breastfeeding?

Please check any conditions that apply to you: PAIN

CRPS

Fibromyalgia

Do you drink alcohol or abuse any types of drugs? If so, please explain:

Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?

Would you like to tell us anything else that you feel like is important?

I attest that the information I have provided is true and accurate to the best of my knowledge:*

Sunday: Closed

Monday: 10:00am to 6:00pm
Tuesday: 10:00 to 6:00pm
Wednesday: 10:00 AM–6:00 PM
Thursday: 10:00am -6:00pm
Friday: 10:00 AM–6:00 PM
Saturday: Closed

CONTACT

Eveciacares@gmail.com

HOURS OF OPERATION

Phone: 732-705-6591

Fax: 732-705-6595

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648 Newark Ave
Elizabeth NJ, 07208. USA

Patient Medical History and Intake Form

Want a physical copy? Feel free to access here.

Scroll down to fill out electronically.

©2023 by Evecia Cares

CONTACT

HOURS OF OPERATION

HOME

ABOUT

SERVICES

TEAM

FORMS

CONTACT