Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Hayes Clinic & SpaPatient Information & Medical HistoryDate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Appointment Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of your appointmentPatient Name *FirstLastDate of Birth *Sex *MaleFemaleUnspecifiedEmail *Primary Phone Number *Work PhoneCan We Leave a Message?HomeCellWorkPlease tick all that applyMailing Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryMedical HistoryPrimary Care Provider: *Current/Recent medications: *Pharmacy: *Please list any allergies including drugs:Please check if you have any of the following:DiabetesHeart DisaseHigh Blood PressureDepressionThyroid DisorderHypoglycemiaAutoimmune IllnessOther:Date of Last EKG/Stress Test: Past Medical History & Surgeries: *Are you pregnant or breastfeeding? *NoYesN/AImmunizations: *FluShinglesPneumoniaHep BTDaPCOVID-19OtherNone ListedLast 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):AliveDeceasedDiabetesHigh Blood PressureObesityHigh CholesterolOtherFather (Please check all that is applicable): AliveDeceasedDiabetesHigh Blood PressureObesityHigh CholesterolOtherSocial History:Do you use tobacco products? *YesNoWhat kind and how much? *Do you consume alcohol? *YesNoWhat kind and how much/often? *What is your goal weight? *Estimated current exercise level: *NoneLowMediumHighHow 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?YesNoIf yes, what do you usually eat when you are bored? *Do you binge eat? *YesNoExample: Feel compelled to eat because of stress.Have you ever used laxatives, diuretics, or vomiting for weight control? *YesNoHave you ever tried prescription medications for weight loss? *YesNoIf yes, when was the last time? *Please check all that you have tried before: *Phentermine (Adipex, Fastin)BelviqSaxendaBenzphetamine (Didrex)Phendimetrizine (Bontril)ContraveOtherType 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, 2003As 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.Smart Scale Results Click or drag files to this area to upload. You can upload up to 2 files. Please upload photo documentation or a screen shot of your Smart Scale weight reading that includes your weight, fat percentage, etc.ID Upload (copy) Click or drag a file to this area to upload. Please upload a clear photo of your state issued ID or Driver’s License.A smart scale is required for all initial TeleMed weight loss appointments. *I understand.Most Recent Lab Work Click or drag files to this area to upload. You can upload up to 3 files. Please upload your lab work. Lab work should include: Lipid Panel, Thyroid Panel (Including Free T3), BMP (Basic Metabolic Panel)Submit