Patient Registration Form Leave this field blank Personal Information Marital Status Single Married Divorced Widowed Date of Birth State Please Select Abia Adamawa, Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu FCT-Abuja Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara Emergency Contact Primary Care Physician Reason for Visit Medical History Allergies Lifestyle and Habits Physical Activity Level: Sedentary Light Activity Moderate Activity Heavy Activity Smoking Status Non-smoker Former Smoker Current Smoker Alcohol Consumption None Social Regular Heavy Medical Checklist Have you had any Operations/Surgery? Yes No Have you had any of the following? Please tick (optional) Asthma Glaucoma Severe Headaches Heart Conditions Epilepsy Cancer Car Accident Other Accidents Skin Conditions Bladder Problem Spinal Fractures Osteoporosis Gynaecological Conditions Pacemaker An aneurysm Stroke Osteoarthritis(Joint wear and tear) Dislocations Rheumatoid arthritis Ligament Injuries Ankylosing spondylitis Cartilage injuries Psoriatic arthritis Lung problems Others Are currently seeing a doctor on any conditions? Yes No Are you are taking any medication(s) currently? Yes No If Yes please list Do you have any injury? Yes No I consent to the collection and use of my personal health information for the purposes of providing medical care. I understand that my information will be kept confidential and used only as required for my treatment and care. Patient Signature Start drawing Clear Done Start over Send
