First name

Last name

Address

Address

City

State

Zip Code

Home Phone

Work Phone

E-Mail

Date of Birth

Have you ever been a patient at an Advanced Healthcare location?
(Check one) Yes  No

Have you ever been a patient at a Columbia St. Mary's Hospital or clinic?
(Check one) Yes  No

Medical conditions (please check all that apply):

Acne
Allergies -(please list below)
     
Arthritis - Osteo
Arthritis - Rheumatoid
Asthma
Bronchitis
Cancer -(please specify below)
     
Diabetes (treatment with diet or exercise)
Diabetes (treatment with pills or insulin)
Eczema / Dermatitis
Gastrointestinal disorders (specify type)
     
Heart disease
High blood pressure
High cholesterol
Hives
Irritable Bowel Syndrome
Migraine headaches
Obesity
Osteoporosis
Psoriasis
Rosacea
Sexual Dysfunction
Other (please list)
     
I authorize the above information to be included in Advanced Healthcare's and Columbia St. Mary's Clinical Research Database. I am aware that Advanced Healthcare and Columbia St. Mary's will not release this information to any outside sources.