Skip to content
Home
Payment
Contact Us
Meet Our Providers
How We Can Help You
Services
Weight Loss Injections
Hormone Therapy
Family Physician Forms
New Patient Application Form
Accepted Patient Registration Form
Weight Loss Injections / Hormone Therapy Form
Worker’s Comp and/or Vehicle & Accident Form
Client Portal
Holli Kautzman Memorial
Blog
Schedule an Appointment
Schedule an Appointment
Weight Loss Injections / Hormone Therapy Form
Kevin Railsback
2024-07-24T17:12:49+00:00
Weight Loss Injections / Hormone Therapy Form
Family Physicians of Cedar Rapids
1515 42nd Street
Cedar Rapids, IA 52402
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 5
Patient Name
*
First
Last
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex
*
Male
Female
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone Number
*
Email
*
Race
White/Caucasian
Black/African American
American Indian/Alaska Native
Asian/Pacific Islander/Native Hawaiian
Other Race
More Than One Race
Unkown
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
More Than One Race
Marital Status
Single
Married
Separated
Divorced
Widowed
Number of Children & Ages
How Did You Hear About Our Practice
*
Referral
Google Search
Social Media
Other
What Services Are You Intersted In?
Weight Loss Injections
Hormone Therapy
Check all that Apply
Next
Emergency Contact
Name
*
First
Last
Phone Number
*
Relationship to the patient
*
Next
Insurance Card(s) required at Appointment
I am the Insurance Holder
Can Skip the Following Section Below If You are the Insurance Holder and the Patient
Name of Insurance Holder
First
Last
Date of Birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Relationship to Patient
Name of Primary Medical Insurance
*
Name of Secondary Medical Insurance if Applicable
Next
Medical History
1) Please Check If You Currently Have Or Have Had Any Of The Following
Asthma
Bleeding Disorder
Cancer
Depression
Diabetes
Elevated Cholesterol
Heart Attack
Hepatitis B
Hepatitis C
Heartburn
Hypertension
Migraines
Nasal Allergies
Seizures
Stroke
Thyroid Disease
Urinating Difficulties
2) Other Please Specify
3) Year of Last Colonoscopy
Was your Colonoscopy...
Normal
Abnormal
N/A
Females Only For Questions #4 & #5
4) Year of Last Pap Smear
Was your Last Pap Smear...
Normal
Abnormal
N/A
Total Number of Pregnancies:
Live Births:
Miscarriages/Abortions:
5) Year of Last Mammogram
Was your Last Mammogram...
Normal
Abnormal
N/A
6) Medications
List medications and dose you are currently taking. Include vitamins and herbal supplements.
7) Do you have any Allergies to any Medications? If yes, please list.
8) Surgeries
Please indicate Past Surgeries (Type & Date).
9) Caffeine
Yes
No
N/A
Drinks/Day
10) Tobacco
Yes
No
N/A
Packs/Day
If Former User of Tobacco
Date Quit
11) Alcohol
Yes
No
N/A
Drinks/Week
12) Exercise
Yes
No
N/A
Type & Times/Week
Next
Family History
1) Cancer
Yes
No
N/A
Family History
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle
Has a Blood Relative ever Had (Check all that Apply).
If Yes in Family History, List Cancer Type.
2) Diabetes
Yes
No
N/A
Family History
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle
Has a Blood Relative ever Had (Check all that Apply).
If Yes in Family History, List Diabetes Type.
3) Heart Attack
Yes
No
N/A
Family History
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle
Has a Blood Relative ever Had (Check all that Apply).
4) High Blood Pressure
Yes
No
N/A
Family History
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle
Has a Blood Relative ever Had (Check all that Apply).
5) Stroke
Yes
No
N/A
Family History
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Aunt
Uncle
Has a Blood Relative ever Had (Check all that Apply).
6) Additional Comments:
Submit
Page load link
Go to Top
