Medical Binder Personal Information

1
Purchaser Name
First Name
Last Name
2
Your Email
example@example.com
3
Phone Number
Please enter a valid phone number.
4
Alternative Phone Number
Please enter a valid phone number.
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Preferred Method of Contact
Home Phone Number
Text
Email
7
Emergency Contact* This field is required.
First Name
Last Name
8
Emergency Contact Phone Number
Please enter a valid phone number.
9
Emergency Contact Email
example@example.com
10
Medical Insurance Coverage
YESNO
11
Name Primary Medical Insurance Provider
12
Medical Card Information
Provider Identification Number
Provider Group Number
Claims Address
Provider Phone Number
13
Upload Your Insurance Card or Cards Upload Front and Back of Card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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14
For Whom is this Binder for?Is there a nickname you go by most?
First Name
Last Name
15
Birthdate
This information is optional.
16
Prescription Coverage
Name of Prescription Insurance Coverage
BIN Number
PCN Number
Group
Member ID
17
Pharmacy Prescription Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Optional
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18
Pharmacy Information
Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
19
MedicinePlease enter all your current Medicines. Don't Forget Vitamins
20
AllergiesPlease enter all your Allergens, including Medicine, Vitamins, Environmental, Food or Animal
21
Current Doctors
22
Previous Doctors
23
Support Staff
24
Caregivers
25
Family HistoryIs there anything in your Family History that Doctors should be aware of or that would cause early preventive screening or early detection?
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Ok
26
Current HealthHow would you describe your current health?
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27
Current or Relevant Previous Health DiagnosisPlease enter any Diagnosis that a Doctor should be made aware of? Are you Taking Medicine for a current heal issue?
28
Medical History (Surgeries or Procedures)* This field is required.Please list any relevant surgeries or procedures. Do you have any metal in your body, have you had a CT, MRI, X-Rays or surgeries in your past that a Doctor should be made aware of?
29
TherapyDo you have different kinds of therapy, please check the boxes that apply, you will be given the opportunity to add more information next.
Physical Therapy
Speech Therapy
Occupational Therapy
Massage Therapy
Other
30
Therapy InformationPlease use this space to expand on the therapies you receive.
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31
VisionDo you have any vision medical needs?
Describe any vision problems you might have.
Name of Doctor that you see.
Enter Eye Doctors Phone number.
32
Eye Prescription
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Upload a copy of your Glasses or Contact Prescription.
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33
DentalDo you have any special Dental Needs?
Describe any Dentalproblems you might have.
Name of Dentist that you see.
Dentist Phone number.
34
Tracking LogsWould you like to include any tracking logs in your Binder? Please note that the Basic only comes with one log. Classic comes with 3 logs and the Ultimate comes with 6 logs. You may chose more at an additional cost. Should you need advanced or more detailed logs you will be given an opportunity to chose 1 of those as well. Also if you do not see what you need there is a section at the end of the form to make special request.
Blood Pressure Log
Sleep Log
Pain Log
Basic Diabetes Log
Seizure Log
Migraine Log
Weight Log
Basic Activity / Exercise Log
Other
35
Advance Tracking LogsWould you like to include any advanced tracking logs in your Binder? Each package Basic and Classic come with 1 selection. The Ultimate comes with 2 selections. You may chose more at an additional cost. Also if you do not see what you need there is a section at the end of the form to make special request.
Advanced Diabetes Log
Weekly Menu Log
Body Mass Index Log
Body Measurements Log
Advanced Exercise Log
Custom Weekly Activity Schedule
Weight Log
Activity / Exercise Log
Other
36
Missing Log?Is there another health condition or activity you would like to track? Give us a brief description of what you are looking for we will create custom logs just for you.
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37
Special RequestDo you have any special request for your binder? How can we customize just for you? Please describe any request here.
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Ok
38
Please click the Yes and then submit if you agree. Click No to cancel or click previous to go back to previous pages.* This field is required.https://ourlittlepeaceofmind.com/hipaa-privacy-policy
YESNO
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