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Patient Information Update

The following sheets are intended solely for use by current Ziering Medical patients.  

If you are not currently under the care of Ziering Medical, we kindly request that you contact our office to set up an appointment before filling out any forms. These sheets contain patient-specific information and are designed to facilitate efficient communication between our medical team and our existing patients. Thank you for your understanding and cooperation. 

Below is our HIPAA compliant and encrypted patient update form, this is a necessary requirement required every 12months to ensure we have the most accurate information.

It will only take a minute if there have been no changes. Thank you any we look forward to continue providing you with the highest quality medications, products and services.

Patient Information Update

Name
Name
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Health History

Answer ALL Questions by Checking YES or NO

Are you in good health?
Has there been any change in your general health in the past year?
Are you currently under a physican's care for a particular medical condition?
Have you EVER had any serious medical conditions or hospitalizations?

Do you have or have you ever had:

Seizures, epilepsy, fainting, stroke or dizziness?
Bleeding disorder, anemia, hemophilia, blood transfusion, Cardiovascular disease (heart attack, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations, heart surgery, stent, pacemaker)?
Lung disease (asthma, emphysema, COPD, tuberculosis, shortness of breath, sleep apnea)?
Bruise easily?
Liver Disease (hepatitis)?
Kidney Disease?
Diabetes?
Thyroid Disease?
Please List ALL prescription medications, over-the-counter medications, herbals, vitamins, and minerals
Do you smoke or chew tobacco?
Do you drink alcohol?
Do you you know what your last blood pressure reading was?
MM slash DD slash YYYY
MM slash DD slash YYYY
Name(Required)
*Please type in your full name as an electronic signature