First Name (required)
Middle Name (required)
Last Name (required)
Your E-mail (required)
Phone number (required)
Date of Birth (required)
Name of Emergency Contact Person (required)
Emergency Contact Phone Number (required)
If you are expecting to receive medication, please tell us your preferred pharmacy. Be more specific (for example, CVS on Franklin in Minneapolis):
Your Housing Status Personal ResidencyGroup HomeShelterFoster Home
Marital Status (required) SingleMarriedDivorcedSeparated
Level of Education Completed (required) High school or GEDSome collegeAssociates or VocationalBachelor's degreeMaster's degreePhD
Are you an army veteran? YesNo
If yes, are you currently on active duty? YesNo
Race WhiteAfrican AmericanAsianHispanic/LatinoAmerican IndianNative HawaiianDecline to Answer
Country of Origin United StatesOther
If Other, kindly name the country of Origin
Is English your primary language YesNo
If No, kindly name your language
Have you ever been involved in any legal issues? YesNo
How did you hear about us? EmployerFriendFamily memberInternet
Who referred you to us?
Do you have any cultural considerations you would like your provider to ask about? YesNo
Do you have any religious considerations you would like your provider to ask about? YesNo
Do you have any concerns about your housing or financial situation? YesNo
Weight
Height
Date of Last Exam (required)
What is/are your reason(s) for seeking services at Emerge Support Services?
Medical History – Please check all that apply
Cardiovascular Coronary artery diseaseHeart surgeryHypertensionAbnormal blood pressureHigh cholesterolFainting spells
Respiratory EmphysemaAsthmaSleep apnea
Endocrine Thyroid problemsDiabetes
General Currently/possibly pregnantCurrently breastfeedingWeight changes
Genitourinary HIV/AIDS/ARCUrinary incontinenceKidney/bladder problemsSexually transmitted disease
Blood/lymph CirrhosisAnemiaHepatitis
Musculoskeletal Broken bone(s)FibromyalgiaChronic fatigue syndromeArthritisRheumatic disease
Neurological HeadachesStrokeHead injuryMemory lossEpilepsy or seizures
Skin Skin disordersTuberculosisAcne
Allergies/Immune ImmunosuppressedHayfever
Gastrointestinal UlcersAbdominal painNauseaDiarrheaConstipation
Auditory/Vision Visual problems other than corrective lensesHearing impaired
Have you ever been hospitalized including psychiatric? YesNo
If yes, please explain:
Have you had or do you currently have cancer? YesNo
Have you had any surgeries? YesNo
Please list any current prescription medications, including dosage:
Please list any food or medication allergies: your answer
Δ