Aloha Nui Family Practice

Aloha Nui Family Practice, LLC                                                                 How did you hear about us? Friend
391 Kilauea Ave., Hilo, HI 96720                                                                                                  Internet/Web site
808.961.1400 808.961.1300(fax)                                                                                                    Newspaper ad
www.AlohaNuiFamilyPractice.com                                                                                               Radio
                                                                                                                                                     Other: _________________

Demographics: *Please also print and complete Service Agreement & Medical Records forms.

DOB: _____ / _____ / ________ Gender: M / F / TG / Other SS#: ______ - ____ - _________

Last Name: ________________________________________ First Name: _________________________ Middle: _________________

Nick name/ Preferred name: ________________________________________________

Residence address: __________________________________________________________________________________________________

Mailing address: ____________________________________________________________________________________________________

Home Phone: ( ) ____________________________ Work Phone: ( ) ___________________________

Cell Phone: ( ) ______________________________ Email: _____________________________________________________________

Occupation: ___________________________________ Employer/School: ____________________________________________________

Emergency Contact Person/Number/Relationship: ___________________________________________________________________________

Do you have a living will? Y / N Do you have a Power of Attorney (POA)? Y / N Whom?: ____________________________________

Insurance Plan(#1): ______________________________________ Insurance Plan(#2): ___________________________________________

Group No./ID No.: _______________________________________ Group No./ID No.: ____________________________________________
____________________________________________________________________________________________________________________

Medical History: (circle all that apply)

High blood pressure / Hypertension CAD / “Heart attacks” / “Chest Pain” CHF / “Heart Failure”

Diabetes / ”High blood sugar” Asthma COPD / Emphysema

Kidney disease Liver disease / Hepatitis (type? _____ ) CVA / Stroke

Anemia / blood disease Thyroid disease Obesity / Overweight

Alcohol dep / addiction Tobacco dep / addiction Drug dep / addiction

Depression / Bipolar disorder Anxiety / Suicidal Schizophrenia / Psychosis

Chronic pain (where? _____________________________________________ ) Neuropathy / Fibromyalgia

HIV / AIDS Hyperlipidemia / ”High cholesterol” Cancer (Colon / Breast / Prostate / Skin / Lung / Bone )

Other medical conditions: _______________________________________________________________________________________________

Allergies: Penicillin / Sulfa / Others : ______________________________________________________________________________________

Surgical History: Appendectomy / Cholecystectomy / CABG / back surgery / Others: _______________________________________________

Social History: Do you smoke? Y / N How many packs each day? _____ Did you ever smoke? Y / N How many years? ______

Drink alcohol? Never / Seldom / Sometimes / Regularly Is alcohol a problem? Y / N Are you in AA or NA? Y / N

Which drugs do you do? __________________________________ Have you ever had treatment for addiction? Y / N

Married / Single / Domestic partner / Divorced / Separated? Number of children?: ____ How many times pregnant? _______

Family History:
High blood pressure / Hypertension Coronary artery disease / “Heart attacks” CHF / “Heart Failure”