Dr. Robert G. Parker New Patient Registration

First Name *

Last Name *

Date of birth *

Sex *

Male

Female

Address *

City *

State *

Postal code *

Phone *

May we leave a message? *

Yes

No

Email *

Primary Language *

English

Spanish

Emergency Contact Name *

Emergency Contact Phone *

Primary Care Doctor *

Pharmacy *

Pharmacy Phone *

If there is another person that you would like for us to share your medical information with, please list them.

Name

DOB

Phone

Primary Insurance

Member ID

Secondary Insurance

Member ID

Medication

Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take
Medication, Dosage, and How Often You Take

Check "Yes" if you would rather provide a list of medications in person. *

Yes

No

Do you have allergies other than seasonal? *

Yes, please list below

No Known Drug

Allergies

Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction
Allergy & Reaction

Check "Yes" if you would rather provide a list of allergies in person. *

Yes

No

Smoking Status *

Current Smoker

Former Smoker

Never Smoked

Past Surgeries

Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date
Type of Surgery and Date

Check "Yes" if you would rather provide a list of past surgeries in person. *

Yes

No

Diabetes *

N/A

Mother

Father

Cancer *

N/A

Mother

Father

Heart Disease *

N/A

Mother

Father

High Blood Pressure *

N/A

Mother

Father

Stroke *

N/A

Mother

Father

Coronary Artery Disease *

N/A

Mother

Father

Thyroid Disorder *

N/A

Mother

Father

Rheumatoid Arthritis *

N/A

Mother

Father

Current Problem *

When did the problem start? *

How did the problem start? *

Suddenly

Gradually

Traumatic

Slowly

Since the problem began, has it: *

Stayed the same

Become worse

Got better than worse

Improved

How would you rate your pain on a scale from 1 to 10? *

Full Name *

Date *

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. *

Clear

1. Do you experience any pain in your legs or feet while are rest? *

Yes

No

2. Do you have uncomfortable aching, fatigue, tingling, cramping or pain in your feet, calves, buttocks, hip or thig during walking/exercise? *

Yes

No

3. If yes to Question 2, does the pain go away when you stop walking/exercising? *

Yes

No

4. Do your feet get pale, discolored, or bluish at any time during the day? *

Yes

No

5. Do you have an infection, skin wound or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks? *

Yes

No

6. Are you over the age of 65? *

Yes

No

7. Are you over the age of 50? *

Yes

No

8. Do you have high cholesterol or other blood lipid (fat) problems or require cholesterol medication? *

Yes

No

9. Do you have high blood pressure or take medication to reduce blood pressure? *

Yes

No

10. Do you have diabetes? *

Yes

No

11. Do you have a history of chronic kidney disease? *

Yes

No

12. Do you currently or have you ever smoked? *

Yes

No

13. Do you have a history of stroke or mini stroke (TIA)? *

Yes

No

14. Do you have a history of heart disease (heart attack, MI)? *

Yes

No

15. Do you have a history of carotid stenosis, AAA (abdominal aortic aneurysm), or stent placement? *

Yes

No

Full Name *

Date *

Please List the Locations of Your Pain Here: *

"I have been advised of my physician's affiliation with Memorial Village Surgery Center and NW Surgery Center and that if I choose to have my surgery performed at any of these facilities, my physician may receive a return on his investment. I understand that I have the right to choose an alternative source of service. I will make an informed choice on where to have my surgery performed." Please Sign in the Box Below. *

Clear

Today's Date *

*If you are having trouble clicking the Submit Button you may have missed a field above, please make sure that you've filled everything out in full 😊