New Patient Paperwork

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Hayes Clinic & Spa

Patient Information & Medical History

Date *

Appointment Date *

Date of your appointment

Patient Name *

First

Last

Date of Birth *

Please make sure that you are selecting the correct year of your birth.

Sex *

Email *

Primary Phone Number *

United States+1
United Kingdom+44
Afghanistan+93
Albania+355
Algeria+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua & Barbuda+1
Argentina+54
Armenia+374
Aruba+297
Ascension Island+247
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Austria+43
Azerbaijan+994
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Bahrain+973
Bangladesh+880
Barbados+1
Belarus+375
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Belize+501
Benin+229
Bermuda+1
Bhutan+975
Bolivia+591
Bosnia & Herzegovina+387
Botswana+267
Brazil+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria+359
Burkina Faso+226
Burundi+257
Cambodia+855
Cameroon+237
Canada+1
Cape Verde+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic+236
Chad+235
Chile+56
China+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros+269
Congo - Brazzaville+242
Congo - Kinshasa+243
Cook Islands+682
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Croatia+385
Cuba+53
Curaçao+599
Cyprus+357
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Denmark+45
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Dominican Republic+1
Ecuador+593
Egypt+20
El Salvador+503
Equatorial Guinea+240
Eritrea+291
Estonia+372
Eswatini+268
Ethiopia+251
Falkland Islands+500
Faroe Islands+298
Fiji+679
Finland+358
France+33
French Guiana+594
French Polynesia+689
Gabon+241
Gambia+220
Georgia+995
Germany+49
Ghana+233
Gibraltar+350
Greece+30
Greenland+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea+224
Guinea-Bissau+245
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Haiti+509
Honduras+504
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Indonesia+62
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Iraq+964
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Israel+972
Italy+39
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Jordan+962
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Kenya+254
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Kosovo+383
Kuwait+965
Kyrgyzstan+996
Laos+856
Latvia+371
Lebanon+961
Lesotho+266
Liberia+231
Libya+218
Liechtenstein+423
Lithuania+370
Luxembourg+352
Macao SAR China+853
Madagascar+261
Malawi+265
Malaysia+60
Maldives+960
Mali+223
Malta+356
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Martinique+596
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Mauritius+230
Mayotte+262
Mexico+52
Micronesia+691
Moldova+373
Monaco+377
Mongolia+976
Montenegro+382
Montserrat+1
Morocco+212
Mozambique+258
Myanmar (Burma)+95
Namibia+264
Nauru+674
Nepal+977
Netherlands+31
New Caledonia+687
New Zealand+64
Nicaragua+505
Niger+227
Nigeria+234
Niue+683
Norfolk Island+672
North Korea+850
North Macedonia+389
Northern Mariana Islands+1
Norway+47
Oman+968
Pakistan+92
Palau+680
Palestinian Territories+970
Panama+507
Papua New Guinea+675
Paraguay+595
Peru+51
Philippines+63
Poland+48
Portugal+351
Puerto Rico+1
Qatar+974
Romania+40
Russia+7
Rwanda+250
Réunion+262
Samoa+685
San Marino+378
Saudi Arabia+966
Senegal+221
Serbia+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia+421
Slovenia+386
Solomon Islands+677
Somalia+252
South Africa+27
South Korea+82
South Sudan+211
Spain+34
Sri Lanka+94
St. Barthélemy+590
St. Helena+290
St. Kitts & Nevis+1
St. Lucia+1
St. Martin+590
St. Pierre & Miquelon+508
St. Vincent & Grenadines+1
Sudan+249
Suriname+597
Svalbard & Jan Mayen+47
Sweden+46
Switzerland+41
Syria+963
São Tomé & Príncipe+239
Taiwan+886
Tajikistan+992
Tanzania+255
Thailand+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad & Tobago+1
Tunisia+216
Turkey+90
Turkmenistan+993
Turks & Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine+380
United Arab Emirates+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan+998
Vanuatu+678
Vatican City+39
Venezuela+58
Vietnam+84
Wallis & Futuna+681
Western Sahara+212
Yemen+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Work Phone

United States+1
United Kingdom+44
Afghanistan+93
Albania+355
Algeria+213
American Samoa+1
Andorra+376
Angola+244
Anguilla+1
Antigua & Barbuda+1
Argentina+54
Armenia+374
Aruba+297
Ascension Island+247
Australia+61
Austria+43
Azerbaijan+994
Bahamas+1
Bahrain+973
Bangladesh+880
Barbados+1
Belarus+375
Belgium+32
Belize+501
Benin+229
Bermuda+1
Bhutan+975
Bolivia+591
Bosnia & Herzegovina+387
Botswana+267
Brazil+55
British Indian Ocean Territory+246
British Virgin Islands+1
Brunei+673
Bulgaria+359
Burkina Faso+226
Burundi+257
Cambodia+855
Cameroon+237
Canada+1
Cape Verde+238
Caribbean Netherlands+599
Cayman Islands+1
Central African Republic+236
Chad+235
Chile+56
China+86
Christmas Island+61
Cocos (Keeling) Islands+61
Colombia+57
Comoros+269
Congo - Brazzaville+242
Congo - Kinshasa+243
Cook Islands+682
Costa Rica+506
Croatia+385
Cuba+53
Curaçao+599
Cyprus+357
Czechia+420
Côte d’Ivoire+225
Denmark+45
Djibouti+253
Dominica+1
Dominican Republic+1
Ecuador+593
Egypt+20
El Salvador+503
Equatorial Guinea+240
Eritrea+291
Estonia+372
Eswatini+268
Ethiopia+251
Falkland Islands+500
Faroe Islands+298
Fiji+679
Finland+358
France+33
French Guiana+594
French Polynesia+689
Gabon+241
Gambia+220
Georgia+995
Germany+49
Ghana+233
Gibraltar+350
Greece+30
Greenland+299
Grenada+1
Guadeloupe+590
Guam+1
Guatemala+502
Guernsey+44
Guinea+224
Guinea-Bissau+245
Guyana+592
Haiti+509
Honduras+504
Hong Kong SAR China+852
Hungary+36
Iceland+354
India+91
Indonesia+62
Iran+98
Iraq+964
Ireland+353
Isle of Man+44
Israel+972
Italy+39
Jamaica+1
Japan+81
Jersey+44
Jordan+962
Kazakhstan+7
Kenya+254
Kiribati+686
Kosovo+383
Kuwait+965
Kyrgyzstan+996
Laos+856
Latvia+371
Lebanon+961
Lesotho+266
Liberia+231
Libya+218
Liechtenstein+423
Lithuania+370
Luxembourg+352
Macao SAR China+853
Madagascar+261
Malawi+265
Malaysia+60
Maldives+960
Mali+223
Malta+356
Marshall Islands+692
Martinique+596
Mauritania+222
Mauritius+230
Mayotte+262
Mexico+52
Micronesia+691
Moldova+373
Monaco+377
Mongolia+976
Montenegro+382
Montserrat+1
Morocco+212
Mozambique+258
Myanmar (Burma)+95
Namibia+264
Nauru+674
Nepal+977
Netherlands+31
New Caledonia+687
New Zealand+64
Nicaragua+505
Niger+227
Nigeria+234
Niue+683
Norfolk Island+672
North Korea+850
North Macedonia+389
Northern Mariana Islands+1
Norway+47
Oman+968
Pakistan+92
Palau+680
Palestinian Territories+970
Panama+507
Papua New Guinea+675
Paraguay+595
Peru+51
Philippines+63
Poland+48
Portugal+351
Puerto Rico+1
Qatar+974
Romania+40
Russia+7
Rwanda+250
Réunion+262
Samoa+685
San Marino+378
Saudi Arabia+966
Senegal+221
Serbia+381
Seychelles+248
Sierra Leone+232
Singapore+65
Sint Maarten+1
Slovakia+421
Slovenia+386
Solomon Islands+677
Somalia+252
South Africa+27
South Korea+82
South Sudan+211
Spain+34
Sri Lanka+94
St. Barthélemy+590
St. Helena+290
St. Kitts & Nevis+1
St. Lucia+1
St. Martin+590
St. Pierre & Miquelon+508
St. Vincent & Grenadines+1
Sudan+249
Suriname+597
Svalbard & Jan Mayen+47
Sweden+46
Switzerland+41
Syria+963
São Tomé & Príncipe+239
Taiwan+886
Tajikistan+992
Tanzania+255
Thailand+66
Timor-Leste+670
Togo+228
Tokelau+690
Tonga+676
Trinidad & Tobago+1
Tunisia+216
Turkey+90
Turkmenistan+993
Turks & Caicos Islands+1
Tuvalu+688
U.S. Virgin Islands+1
Uganda+256
Ukraine+380
United Arab Emirates+971
United Kingdom+44
United States+1
Uruguay+598
Uzbekistan+998
Vanuatu+678
Vatican City+39
Venezuela+58
Vietnam+84
Wallis & Futuna+681
Western Sahara+212
Yemen+967
Zambia+260
Zimbabwe+263
Åland Islands+358

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical History

Primary Care Provider: *

Current/Recent medications (please include dosage): *

Pharmacy: *

Please list any allergies, including drugs:

Please check if you have any of the following:

Diabetes
Heart Disase
High Blood Pressure
Depression
Thyroid Disorder
Hypoglycemia
Autoimmune Illness

Other:

Date of Last EKG/Stress Test:

Past Medical History & Surgeries: *

Are you pregnant or breastfeeding? *

Immunizations: *

Flu
Shingles
Pneumonia
Hep B
TDaP
COVID-19
Other
None Listed

Last Physical Exam:

Last Lab Work:

Date of Last Colonoscopy:

Date of Last Pap Smear:

Date of Last Bone Density:

Date of Mammogram:

Family Health History:

Mother (Please check all that is applicable):

Alive
Deceased
Diabetes
High Blood Pressure
Obesity
High Cholesterol
Other

Father (Please check all that is applicable):

Alive
Deceased
Diabetes
High Blood Pressure
Obesity
High Cholesterol
Other

Social History:

Do you use tobacco products? *

What kind and how much? *

Do you consume alcohol? *

What kind and how much/often? *

What is your goal weight? *

Estimated current exercise level: *

None
Low
Medium
High

How many meals do you usually eat each day? *

How many times a week do you eat out? *

About how many 12 oz cans of soda do you drink in a day? *

How many glasses of sweetened tea/coffee do you drink in a day? *

How many 8 oz glasses of water do you drink each day? *

Do you eat when you are bored?

If yes, what do you usually eat when you are bored? *

Do you binge eat? *

Example: Feel compelled to eat because of stress.

Have you ever used laxatives, diuretics, or vomiting for weight control? *

Have you ever tried prescription medications for weight loss? *

If yes, when was the last time? *

Please check all that you have tried before: *

Phentermine (Adipex, Fastin)
Belviq
Saxenda
Benzphetamine (Didrex)
Phendimetrizine (Bontril)
Contrave
Other

Type your full name to electronically sign this paperwork: *

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Notice of Privacy Practices:

Hayes Clinic 520 N Collegiate Drive Paris, TX 75460 License Number: H 9983 Effective Date: April 1, 2003

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Our office strives to protect your privacy in all phases of care we provide for you. Your records can only be released to another party if you have given our office written permission for us to do so. This protection covers the release of information to pharmacies, other doctors, and insurance companies. We must have your written permission on file before we can release your information. On file in our office, we have a complete copy of the NOTICE OF PRIVACY PRACTICES/HIPAA FORMS, and you are entitled to a copy of this notice upon request. Please contact our staff if you would like a copy. By signing below, you show that you have been advised of our privacy practices. *

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

ID Upload

Click or drag a file to this area to upload.

Please upload a clear photo of your state issued ID or Driver’s License.