Pre Visit Planning Form
If you are under 12 years old, please fill this form with your parents.
Who is filling this form?
Patient
Parent
Other
Name of Patient
First Name
Last Name
Date of Birth of Patient
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have one of the following conditions?
Rows
Yes
No
Any medications used
Diabetes
1
2
High Blood Pressure
3
4
High Cholesterol
5
6
Depression
7
8
Shortness of Breath
9
10
Weight of Patient
Hight of Patient
Does patient have regular exercise habit?
Yes
No
Does patient expose with smoke or vape?
Yes
No
Does patient get help from psychological consulting?
Yes
No
Does patient have appetite?
Yes
No
Does patient have allergies?
Yes
No
What are patient allergic to?
How much caffeine patient consume?
None
1 cup
1-3 cups
More than 3 cups
Does patient have any following nonspecific symptoms?
Weight loss
Headache
Chronic pain
Fatigue
Night sweats
Other
Submit
Should be Empty: