New Patient Form

Internal Medicine Associates of Lincoln Park

Dr Anju Budhwani
General Patient Information
Patient Name *

Prefix First Name Last Name
Date of Birth *

Month Day Year
Cell Number *

Area Code Phone Number
Home Number

Area Code Phone Number
Preferred Phone Number

Cell Home
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Birth Date *

Month Day Year
Patient Gender
Patient Ethnicity
Patient E-Mail *
Emergency Contact Name:

First Name Last Name
Emergency Contact Phone:

Area Code Phone Number
What brings you in to our office?

Sleep Pulmonary Primary Care
Please describe what issues bring you in today. Include any signs or symptoms, as well as approximate time period present. *
How did you find our office?
Insurance Information
Subscriber's Name (if not patient)

First Name Last Name
Relation to Insurance Subscriber:

Self Spouse Dependent (child)
Subscriber Date of Birth (If Not Patient)

Month Day Year
Patient Medical History
I have no medical history
General

High Blood Pressure High Cholesterol
Cardiac

Atrial Fibrillation Arrhythmia Congestive Heart Failure Coronary Artery Disease Heart Attack Heart Valves/Stents Pacemaker/Defibrillator
Endocrine

Diabetes - Type One Diabetes - Type Two Thyroid Disease
Gastroenterology

Diverticulitis/osis GERD/Heartburn Hepatitis/Liver Disease Stomach Ulcers Pancreatic Disease
Neurology

Migraines Peripheral Neuropathy Seizures Stroke TIA
Other

Arthritis Autoimmune Disease Depression/Anxiety Fibromyalgia Gout HIV/AIDS
Pulmonary/Sleep

Asthma COPD Emphysema Narcolepsy Oxygen Dependence Pneumonia Sleep Apnea
Please list any drug allergies (if none, please click "I have no known allergies, below)
Other Allergies: (if none, please click "I have no known allergies, below)
I have no known allergies
Please list any surgeries and dates of each
Please list your current medications (with dosage and # of times per day)
Please list any over the counter medications or supplements you take.
I take no medications at this time
Pharmacy Name:
Pharmacy Address

Street Address

Street Address Line 2

City State

Zip Code
Please list any family history (medical history of biological family) *
COVID-19 Questionnaire

At this time, this is required to protect ourselves and our patients. If you answer yes to any of these questions, we MAY request to see you virtually rather than in person.
IN THE PAST TWO WEEKS: Have you had a fever, sore throat, or cough? *

Yes No
IN THE PAST TWO WEEKS: Have you traveled outside of the state? *

Yes No
IN THE PAST TWO WEEKS: Have you come in contact with anyone suspected to have, or confirmed to have, the COVID-19 virus? *

Yes No
Have you EVER been tested for the COVID-19 virus? (nasal swab, or saliva test) *

Yes No
Have you EVER had COVID-19? *

Yes No
Have you EVER been tested for the COVID-19 antibodies? (blood test) *

Yes No
Do you believe you may currently have COVID-19? *

Yes No
Doctors
Primary Care Doctor:
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cardiologist:
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Other Doctor & Specialty
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Healthy & Unhealthy Habits
Exercise - 30+ minutes daily

Never 1-2 days 3-4 days 5+ days
Alcohol Consumption *

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day
Caffeine Consumption *

I don't use caffeine 1-2 cups/day 3-4 cups/day 5+ cups/day
Do you CURRENTLY smoke? *

No 0-1 pack/day 1-2 packs/day 2+ packs/day
Are you a PAST smoker?

No Yes, 0-1 pack/day Yes, 1-2 packs/day Yes, 2+ packs/day
If you have quit smoking, what year did you quit?
If you are, or have ever been a smoker, for how long have you/did you smoke?
Do you vape, or chew tobacco?

Yes No
Do you use illicit drugs, including marijuana?

Yes No
Social History
Occupation
Employer
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Marital Status
Number of Children & Ages of Children
Insurance Card - FRONT

Upload Insurance Card Front

Cancel of
Insurance Card - BACK

Upload Insurance Card Back

Cancel of
License/Identification Card

Upload ID

Cancel of
Any past labwork, scans, etc. the doctor may need for your visit:

Browse Files
Upload multiple files, if necessary. Cancel of
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Internal Medicine Associates of Lincoln Park to release any information required to process my claims.
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Internal Medicine Associates of Lincoln Park

General Patient Information

Insurance Information

Patient Medical History

COVID-19 Questionnaire

Doctors

Healthy & Unhealthy Habits

Social History