Patient Registration
EXPRESS HEALTH SYSTEMS
Patient Registration
Patient Name
*
First Name (as appears on License/Identification)
Last Name (as appears on License/Identification)
Middle Name (optional)
Maiden Name (if applicable)
Date of Birth
*
Please enter 2 digits for month and day, 4 digits for year (ex. Month of January = 01, 3rd day of Month = 03).
Address
*
Street Address
Street Address Line 2
City
Alaska
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Gender
*
Male
Female
Email Address
*
Phone Number
*
Were you referred to Express Health Systems by another Patient?
*
Yes
No
First and Last name of the patient who referred you:
*
If you wish to receive any information or promotions from Express Health Systems:
*
No Thank You
Email
Text (carrier charges may apply)
Mail
Medical History
Current/Past Medical History - Check all that apply:
*
None
High Blood Pressure
Heart Attack
Diabetes Mellitus
Hypothyroid (Abnormally low activity of the thyroid)
Hyperthyroid (Over-activity of the thyroid)
Reflux
Glaucoma
Coronary Artery Disease
Stroke
High Cholesterol/Triglycerides
Congestive Heart Failure
ADD/ADHD
Medical History Other (Please explain):
Medical History Other (Please explain):
Heart Attack Date
*
Stroke Date
*
Past Surgical History - Check all that apply:
*
None
Hysterectomy
Tubal Ligation
Gallbladder Removal
Appendectomy
Coronary Stents
Coronary Artery Bypass Graft
Carotid Endarterectomy
C-Section
Past Surgery Other (Please explain):
Past Surgery Other (Please explain):
Social History - Check all that apply:
*
None
Cigarettes
Smokeless Tobacco
Alcohol Consumption
Illicit Drugs
Alcohol Consumption Frequency:
*
Infrequent Social Drinking
Frequent Small Amounts
Frequent Large Amounts
Illicit Drugs:
*
Review of Symptoms - Check all that apply:
*
None
Swelling
Fatigue
Skin, Hair, or Nail Problems
Excess Weight
Eating Habits - Check all that apply:
*
None
Large Portions
Sweets/Snacks
Carbonated Drinks
Allergies & Medications
Allergies to Medications:
*
Yes
No
Edit
Allergies to Food:
*
Yes
No
Edit
Current medications, supplements, vitamins, or herbs:
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Physical Activity
Do you exercise?
*
Yes
No
How many days per week?
*
1
2
3
4
5
6
7
How long do you exercise?
*
30 minutes
30-60 minutes
> 60 minutes
What kind of exercise do you do?
*
Walking
Jogging/Running
Mixed cardio
Swimming
Other
Other exercise:
Confirmation
EXPRESS HEALTH SYSTEMS
Acknowledgement:
*
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Allergies to Medications
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Appetite Suppressants
Phentermine (Adipex, Lomaira)
Phendimetrazine (Bontril)
Semaglutide (Wegovy, Ozempic, Rybelsus)
Contrave (Naltrexone/Bupropion)
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Antibiotics
Penicillin (PCN VK)
Amoxicillin (Amoxil)
Augmentin (Amoxicillin/Clavulanate)
Penicillin G (Bicillin LA, Bicillin CR)
Ampicillin
Cephalexin (Keflex)
Cefdinir (Omnicef)
Cefixime (Suprax)
Cefpodoxime proxetil
Cefaclor (Ceclor)
Ceftriaxone (Rocephin)
Cefazolin (Ancef)
Cefoxitin (Mefoxin)
Cefuroxime (Zinacef)
Cefepime (Maxipime)
Sulfamethoxazole/Trimethroprim (Bactrim, Septra, Sulfatrim)
Sulfasalzine (Azulfidine)
Levaquin (Levofloxacin)
Cipro (Ciprofloxacin)
Avelox (Moxifloxacin)
Ofloxacin
Baxdela (Delafloxacin)
Tetracycline
Doxycycline (Vibramycin, Acticlate, Avidoxy, Doryx, Morgidox, Oracea, Targadox)
Minocycline (Minocin, Minolira, Solodyn)
Tigecycline (Tygacil)
Nitrofurantoin (Macrobid, Macrodantin, Furadantin)
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NSAIDS (Non-Steroidal Anti-Inflammatory Drugs)
Ibuprofen (Advil, Motrin, Caldolor)
Naproxen (Aleve, Naprosyn, Naprelan)
Aspirin
Acetominophen (Tylenol)
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Narcotic Pain Medications
Codeine
Hydrocodone (Norco, Lortab)
Tramadol (Ultram, ConZip)
OxyContin (Oxycodone)
Morphine (MS Contin, Kadian)
Fentanyl
Dilaudid (Hydromorphone)
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Hypertension and/or Heart Medications
Lisinopril (Zestril, Qbrelis)
Losartan (Cozaar)
Amlodipine (Norvasc, Katerzia, Norliqva)
Digoxin (Lanoxin)
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Monoclonal Antibody Therapy
Cetuximab (Erbitux)
Rituximab (Rituxian)
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Blood Thinners
Coumadin (Warfarin)
Eliquis (Apixaban)
Xarelto (Rivaroxaban)
Pradaxa (Dabigatran)
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Insulin
Regular insulin or insulin NPH (Humulin, Novolin)
Humalog (Insulin Lispro)
Novolog (Insulin Aspart)
Lantus (Insulin Glargine)
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Muscle Relaxants
Flexeril (Cyclobenzaprine)
Robaxin (Methocarbamol)
Skelaxin (Metaxalone)
Norflex (Orphenadrine)
Carisoprodol (Soma)
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Anesthesia
Succinylcholine
Vecuronium
Atracurium
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Antiseizure
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Phenytoin (Dilantin)
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HIV Medications
Abacavir (Ziagen)
Nevirapine (Viramune)
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Other
Chemotherapy Medications
Iodine
Contrast Dye
Not Listed
Reactions -
Unknown
Rash
Itching
Swelling
Difficulty Breathing
Anaphylaxis
Nausea
Vomiting
Other
Other
Allergies - Not Listed
Allergies to Food
Gluten
Peanuts or other nuts
Eggs
Milk or dairy
Shellfish (Crustaceans, such as shrimp, prawns, crab, or lobster)
Mulluscs (such as mussels, clams, oysters, snails, or slugs)
Fish
Soybeans
Food dyes
Not Listed