New patient Form Please fill in as much information as possible to expedite your visit scheduling. Any further details can be discussed in personPlease enable JavaScript in your browser to complete this form.First Name *Last Name *Your Email *Date of BirthAddress Street, City, Zip Code, State, CountrySexChoice 1FemaleMaleLast primary care physician / provider nameHow did you find Dr. LeyceguiWeb SearchGoogle ReviewsFriendFamilyWork ColleaguePhysician recommendationYouTubeInstagramDiagnosis EstablishedDiabetesHypertensionHigh cholesterolFatty liverGoutThyroid diseaseParathyroid diseaseLow testosteroneAtrial fibrillationCongestive heart failureSleep ApneaKidney diseasePancreatic problemsRheumatoid arthritisLupus / Autoimmune diseasesAsthmaCOPD/ EmphysemaMigraineVertigoSeizuresStrokeDecreased hearingRinging in the earsPsoriasisOsteoporosis/osteopeniaGERD / RefluxGastric UlcersTuberculosisHelicobacter PyloriEndometriosisAnemiaFibroids-UterineCrohns DiseaseUlcerative ColitisIBSKidney Stones CalciumKidney Stones - Non calciumEnlarged prostateChronic urinary tract infectionsEnlarged ProstateAneurysmBlood ClotsAlzheimer's diseaseParkinson's disease/tremorsMood disorder: depression/ anxiety/ etc.SchizophreniaSTD's ( may leave blank- in person with doctor can discuss)Select all that applyCancer TypeProstateBreastOvarianCervicalLungBrainThyroidLiverOral / ThroatLaryngealMelanomaOther Skin NOT MelanomaLymphomaLeukemiaMultiple MyelomaEsophagealGastricPancreaticColon / RectalSarcoma-muscleTesticularBladderKidneyPenisSelect all that applySurgeries / ProceduresC-Section(s)Pregnancy Vaginal Delivery(s)AppendixGallbladderCataractGlaucomaRetinal detachmentCorneaThyroidStomache including BariatricHerniaHipKneeShoulderCarpal tunnelBack-LumbarNeck-CervicalHysterectomy TotalHysterectomy PartialOvary Removal / cystBreast Implants / ReconstructionTummy TuckFace LiftBBL / ImplantsRhinoplasty / SeptoplastyVasectomyPace Maker / DefibrillatorHeart BypassHeart StentCarotid SurgeryAneurysm SurgerySelect all that applyCurrent issues – symptoms you would like to discuss in your initial visitExpand as much as you'd like.Past medical history - Continued : Diagnosis/Surgeries/ Hospitalizations (Add especially if not above))Medication Allergies *Only to Medication's, do not include environmental, food allergies in this section. if none type None.Family HistoryBreast CancerOvarian CancerLung CancerColon CancerProste CancerHeart attacksStrokeAlzheimer's diseaseParkinson's disease/tremorsSchizophreniaAutoimmune diseasesThyroid diseaseHigh cholesterolDrug/ Alcohol issuesTuberculosisAsthmaAllergiesOccupation: if retired past occupation. Any exposure to dangerous chemicals/ compounds in the present or past? *Alcohol - Drinks per week on averageI do not drink Alcohol0-32-77-1010 or moreExercise: 30 minute or more- sessions per week01-33-55-7Coffee Cups / Shots per day Selected Value: 0 Recreational DrugsLeave blank, if noneTobacco Smoking StatusNeverCurrent smokerCurrent VapingQuit smokingQuit VapingIf smoker have you had a CT scan of the chest for lung cancer screening?If yes, approximate date, and did you have any pulmonary nodules?ColonoscopyNeverYes- with no polypsYes- with 1-3 polypsYes- with 3 or more polypsIf you had a Colonoscopy - please provide approximate date of last one.When was your last mammogram? (Approximate date if unsure)When was your last Pap smear? (Approximate date if unsure)Do you have a GYN? if you do, please type name Date of last Bone density test? if never or unknown leave blankDate of last PSA test? if never or unknown leave blankIf you had a cardiac catheterization, please type approximate dateIf you had a stress test, please type approximate dateHave you had a tetanus vaccination in the past five years?YesNoNot sureHave you had an influenza vaccination in the past year?YesNoNot sureHave you had a pneumonia vaccination in the past five years?YesNoNot sureHave you ever had that tuberculosis vaccine BCG?Choice 4YesNoNot SureHave you ever had the COVID-19 vaccine / boosters ?Choice 4YesNoNot SureInfectious disease / developmental – have you ever had the following choose all that applyMeaslesMumpsRubellaChicken PoxWhooping coughDiphteriaHepatitis AHepatitis CHepatitis BHelicobacter PyloriHPVHerpes type 1Herpes type 2TuberculosisCOVID-19Current medication'sPlease list your current medications. If the list is extensive, you may attach the list or bring your medications or their list to your appointment.Primary Phone Number for Contact *Emergency contact nameEmergency contact phone numberWe communicate via email, text messages, and voice calls. Do we have your permission to contact you through these methods? *YesNoWhile we do not accept insurance, we still require insurance information to electronically send bloodwork, radiology, and other tests. Please provide the details below. Alternatively, you can furnish this information during your visitSignature *Type First and Last NameMessageSubmit
