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Patient Info

Name: Micah Alex Harrison

Date of Birth: July 18th, 1996

Address:
11 W. Carpenter Drive
Bakersfield, CA 93306

Contact Info:
(667) 531-5220
Micah.Harrison@gmail.com

Emergency Info:
Mother: (667) 804-0270
Aimee.Harrison@gmail.com
Father: (667) 678-1281
Karter.Harrison@gmail.com

Insurance/Health Care/Co-Pay:
Blue Cross Blue Shield of California. Account Number: 197522198995442


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General Information

Confirm Name and DOB

Name:
DOB:

How would you like to be addressed?
Former Names Is there a chance of any other records under another name? Yes No
If Yes
Other Possible Names:

General Health Height:
Weight:
Temperature:
Blood Pressure:
Heart Rate:

Physical Exam:
Reflexes:
Lungs:
Heart:
Digestion:
Neck:
Spine:
Common Immunizations Completed:
MMR
HPV
Rotavirus
Smallpox
Chickenpox
Hepatitus A
Flu Shot
Polio
Rabies
Current Medications and Presciptions:

Family Health History:

Do you have any Allergies?
Yes
No
  If Yes, what type and how bad?:
  
Are you sexually active?
Yes
No

Have you been out of the country recently?
Yes
No
  If Yes, where at and for how long?:
  

How often do you exercise?


Alcohol and Cigarettes Do you smoke or have you smoked in the past?
Yes
No
  If Yes, How often?
  
  If previous smoker, When did you quit?
  

Do you drink alcohol?
Yes
No
  If Yes, How much and how often?
  

Sleep and Recent Food Consumption: On average, how much sleep are you getting each night?


Do you sleep well?
Yes
No

When did you last eat?


Reason for Visit?



  • Check-Up
  • Mental Health
  • Sickness
  • Scan or Procedure



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    CHECK-UP

    Possible Body Pain What hurts? Check all that apply.
    Toes Feet Ankle Calf Knee Leg
    Thigh Hip Torso Ribs Back Head
    Fingers Wrist Elbow Shoulder Neck

    Pain Scale
    1 2 3 4 5 6 7 8 9 10
    How long has it been around?
    Do you have an idea where it came from or how it happened?
    Do you have any current or long lasting injuries?

    Have you had any surgeries in the last year?
    Yes
    No
      If Yes, when and what on?
      
    Do you struggle with either anxiety or depression? Diagnosed or undiagnosed?
    Yes
    No


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    MENTAL HEALTH

    Possible Body Pain What hurts? Check all that apply.
    Toes Feet Ankle Calf Knee Leg
    Thigh Hip Torso Ribs Back Head
    Fingers Wrist Elbow Shoulder Neck

    Pain Scale
    1 2 3 4 5 6 7 8 9 10
    How long has it been around?
    Do you have an idea where it came from or how it happened?
    Do you have any current or long lasting injuries?

    Have you had any surgeries in the last year?
    Yes
    No
      If Yes, when and what on?
      
    Do you struggle with either anxiety or depression? Diagnosed or undiagnosed?
    Yes
    No

    Mental Health Checklist:
    Lack of Energy
    Lack of Motivation
    Mood Swings
    Changes in Sleep Patterns
    Changes in Appetite
    Alarming Changes in Weight
    Difficultly Concentrating
    Loss of Confidence
    Loss of interest in passions
    Past Diagnosed Personal History with Anxiety
    Past Diagnosed Personal History with Depression


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    SICKNESS

    Possible Body Pain What hurts? Check all that apply.
    Toes Feet Ankle Calf Knee Leg
    Thigh Hip Torso Ribs Back Head
    Fingers Wrist Elbow Shoulder Neck

    Pain Scale
    1 2 3 4 5 6 7 8 9 10
    How long has it been around?
    Do you have an idea where it came from or how it happened?
    Do you have any current or long lasting injuries?

    Have you had any surgeries in the last year?
    Yes
    No
      If Yes, when and what on?
      
    Do you struggle with either anxiety or depression? Diagnosed or undiagnosed?
    Yes
    No

    Mental Health Checklist:
    Lack of Energy
    Lack of Motivation
    Mood Swings
    Changes in Sleep Patterns
    Changes in Appetite
    Alarming Changes in Weight
    Difficultly Concentrating
    Loss of Confidence
    Loss of interest in passions
    Past Diagnosed Personal History with Anxiety
    Past Diagnosed Personal History with Depression

    Symptoms or Current Issues:
    cough
    general body pain
    weakness
    blurry vision
    fever
    lumps on throat
    abdominal pain
    chest pain
    headaches
    nausea or vomiting
    dizziness
    shortness of breath
    sore throat
    urinary issues
    numbness
    swelling


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    SCAN/PROCEDURE

    Possible Body Pain What hurts? Check all that apply.
    Toes Feet Ankle Calf Knee Leg
    Thigh Hip Torso Ribs Back Head
    Fingers Wrist Elbow Shoulder Neck

    Pain Scale
    1 2 3 4 5 6 7 8 9 10
    How long has it been around?
    Do you have an idea where it came from or how it happened?
    Do you have any current or long lasting injuries?

    Have you had any surgeries in the last year?
    Yes
    No
      If Yes, when and what on?
      
    Do you struggle with either anxiety or depression? Diagnosed or undiagnosed?
    Yes
    No

    Mental Health Checklist:
    Lack of Energy
    Lack of Motivation
    Mood Swings
    Changes in Sleep Patterns
    Changes in Appetite
    Alarming Changes in Weight
    Difficultly Concentrating
    Loss of Confidence
    Loss of interest in passions
    Past DIagnosed Personal History with Anxiety
    Past Diagnosed Personal History with Depression

    Symptoms or Current Issues:
    cough
    general body pain
    weakness
    blurry vision
    fever
    lumps on throat
    abdominal pain
    chest pain
    headaches
    nausea or vomiting
    dizziness
    shortness of breath
    sore throat
    urinary issues
    numbness
    swelling

    Do you have any metal in/on your body?
    Yes
    No
    Is there someone with you today?
    Yes
    No

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