CONSULTATION FORM

ABRAMS ROYAL PHARMACY NEW PATIENT CONSULTATION FORM
Welcome to Abrams Royal Pharmacy! We are so happy that you have chosen us to help guide you on your health care journey. Our goal is to provide you with accurate and up to date information to help you make informed choices regarding your health. Please complete this form in its entirety at least two (2) business days prior to your appointment if possible. If you have any recent lab work, please attach those douments to this form.

If you are unable to make your appointment, please call the pharmacy at least 24 hours in advance so we may contact clients on our wait list.
Name *

First Name Last Name
DOB *

Month Day Year
Date
Sex *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Which location will you be having your consultation? *
Height: Feet   Inches

Current Weight: Pounds
Ideal Weight: Pounds

Handedness:

Blood Type:
ABO Secretor:

Occupation:
Hours worked per week:

Number of Children:
Children's Ages:
Who is your Primary Care provider?   Please list here

Date(s) of last lab workup(s)   Date
(Please upload any relevant labwork at the end of this form)

How did you hear about us? (Please choose all that apply)

Referred by Dr or Clinic   Please tell us who to thank

Friend or Family   Please tell us who to thank

Internet or Social Site   Which one(s)?

Printed Ad or Publication   Which one(s)?

Other   Please state here
Please list your main health concerns in order of their importance
Please list any allergies you have (seasonal, chemical, food, meds...)
Please list your current prescription medications
Please list your current over the counter medications
Please list your current vitamins and herbal supplements
Please list any medical conditions/surgeries and dates
Conditions/Surgeries   Date
Conditions/Surgeries   Date
Conditions/Surgeries   Date
Conditions/Surgeries   Date
Conditions/Surgeries   Date
Please list any family history of disease and familial relationship below
Condition   Relationship
Condition   Relationship
Condition   Relationship
Condition   Relationship
Condition   Relationship
Diet/Lifestyle Information

How many days per week do you exercise?      What type of exercise do you perform?

Have you had your usual childhood vaccines?

Do you get the flu shot every year?   Always   Sometimes   Rarely   Never

How regularly do you skip meals?  Always   Sometimes   Rarely   Never

Do you eat organically?  Always   Sometimes   Rarely   Never

How often do you eat out? Always   Sometimes   Rarely   Never

Do you consume sodas/sports drinks/flavored water?  Always   Sometimes   Rarely   Never

How much alcohol do you drink per week?

How much water do you drink per day?

Do you consume chemical sweeteners, if yes which ones?

Do you consume natural sweeteners, if yes which ones?

What is your tobacco/vape use?   Smoke   Chew/Dip   Vape   None
Please upload additional labwork or relevant documents here

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Signature

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Date

Month Day Year
Date
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ABRAMS ROYAL PHARMACY NEW PATIENT CONSULTATION FORM