Jennifer Lee, FNP

1314 S King St STE 604, Honolulu, HI 96814

Confidential Medical Information

Please complete this form accurately. All information is kept confidential and used to provide safe, coordinated, and personalized care.

PATIENT INFORMATION:

First Name

Last Name

Date Of Birth

Age

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

Emergency Contact

Emergency contact phone number:

Relationship to Patient (if applicable):

PRIMARY CARE PROVIDER/REFERRING PROVIDER

Physician Name/Practice

Physician Number:

May we coordinate with your provider?

Yes

No

Describe your main goals or concerns:

SURGICAL HISTORY: (Please list any past surgeries and approximate date)

CURRENT MEDICATIONS: (List all prescription medications)

SUPPLEMENTS/VITAMINS: (List all supplements, herbs, or over-the-counter products)

ALLERGIES:

Yes

No

List all allergies that apply:

Medications
Foods
Latex
Other

Describe allergic reaction(s):

LIFESTYLE & WELLNESS

How would you rate your current stress level:

Low

Moderate

High

Average sleep per night:

<5 hrs

5-6 hrs

7-8 hrs

>8 hrs

Exercise frequency:

None

1-2 times/week

3-4 times/week

5+ times/week

Alcohol use:

None

Occasional

Moderate

Frequent

Tobacco/Nicotine use:

Yes

No

IV THERAPY & WELLNESS SCREENING

Have you ever had IV Therapy before?

Yes

No

Have you ever experienced adverse reactions to IV therapy?

No

Yes

Explain:

Are you currently feeling ill, feverish, or dehydrated?

Yes

No

PATIENT ACKNOWLEDGEMENT & CONSENT

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that health and wellness services are not a substitute for primary medical care and agree to coordinate care when appropriate.

Signature:

Clear

Date:

FOR CLINIC USE ONLY:

Reviewed by:

Date

Notes: