FxMedSupport Apostol First Name * Middle Name (or initial) Last Name * Date of Birth * MM slash DD slash YYYY Social Security NumberNickname/Preferred Name Gender *- Select One -MaleFemaleRace- Select One -WhiteBlackHispanicAsianNative AmericanMixed/OtherEthnicity- Select One -Hispanic or Latinonot Hispanic or LatinoOtherYour Address Address 1 * Address 2 City * State/Province * Zip Code *TimezoneAmerica/ChicagoEASTERNCENTRALMOUNTAINMOUNTAIN/ARIZONAPACIFICALASKAHAWAII(UTC-11:00) Pacific/Midway(UTC-11:00) Pacific/Niue(UTC-11:00) Pacific/Pago Pago(UTC-10:00) Pacific/Rarotonga(UTC-10:00) Pacific/Tahiti(UTC-09:30) Pacific/Marquesas(UTC-09:00) America/Adak(UTC-09:00) Pacific/Gambier(UTC-08:00) America/Yakutat(UTC-08:00) America/Nome(UTC-08:00) Pacific/Pitcairn(UTC-08:00) America/Anchorage(UTC-08:00) America/Metlakatla(UTC-07:00) America/HermosilloContact Information Mobile Phone NumberHome Phone NumberWork Phone NumberPreferred Contact NumberMobile PhoneHome PhoneWork PhoneOtherEmail Address (Primary) * Secondary Email Address Home Fax NumberContact Preferences Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails)Email:Yes (opt-in)No (opt-out)SMS/Text:Yes (opt-in)No (opt-out)Insurance Information First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number * Emergency Contact Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists)Plan Name Group Number Member ID Insurance Type Medical Information Please enter your basic medical information below. You may also add or edit this information after you've signed up. Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations)Relevant Family Medical History (indicate which family member if applicable)CURRENT CONCERNS What do you hope to achieve in your visit with us?When was the last time you felt well? Did something trigger your change in health? What makes you feel worse? What makes you feel better? How do you spend your days?What makes you feel better? Please list current and past problems in order of priority: Describe Problem Mild Moderate SevereMildModerateSeverePrior Treatment/Approach Mild Moderate SevereExcellentGoodFairPoorproblem 1 problem 1 Ans Mild Moderate Severe Approach 1 Approach 1 Ans Excellent Good Fair Poor problem 2 problem 2 Ans Mild Moderate Severe Approach 2 Approach 2 Ans Excellent Good Fair Poor problem 3 problem 3 Ans Mild Moderate Severe Approach 3 Approach 3 Ans Excellent Good Fair Poor problem 4 problem 4 Ans Mild Moderate Severe Approach 4 Approach 4 Ans Excellent Good Fair Poor problem 5 problem 5 Ans Mild Moderate Severe Approach 5 Approach 5 Ans Excellent Good Fair Poor Enter the number that corresponds to frequency of symptoms: 1 = occasional, 2 = weekly, 3 = almost daily or daily. Leave blank if less than once a month or does not occur. For questions accompanied by a check box, check the box if the symptom regularly occurs.AdrenalDeficiencyExcessDeficiency "Second wind" of energy at night Difficulty falling asleep Feel worse after exercising Chronic low back pain Easily dizzy upon standing Arthritis or arthralgia (bone/joint pain) Crave salty foods Allergies, food intolerances, and/or hives Shin splints and/or easily spraining ankles Perspire easily Afternoon headache Excess Feel wired or jittery after coffee Clench or grind teeth Trouble calming down Persistent headaches for no apparent reason Set Username and Password for Patient Portal Please create a username and password that you will use to log into the patient portal in the future. Your username must be at least 4 characters longUsername * Your password must be at least 8 characters long and include at least one number or special character.Password * Enter Password Confirm Password The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.Untitled I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." Untitled "I have read and accept the terms of the privacy policy below:" * Signature
