Welcome
Meet Our Staff
Services
Conditions We Treat
Corporate Wellness
Our Patients Speak
Contact Us
Careers
Wellness Topics
Health & Wellness Survey
New Patient Information
EmailMeForm
Health & Wellness Survey
Allegheny Health & Physical Medicine
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country
Phone
*
###
-
###
-
####
Email
Date of Birth
*
MM
/
DD
/
YYYY
Occupation
Which Area Are You Closest To?
*
Gibsonia
Brackenridge
Monroeville
Health Information
_____________________________________________________________________
Check Any Of The Following You Have Experienced In The Past 6 Months:
Headaches/Migraines
Fatigue
Insomnia/Sleep Problems
Digestive Trouble
Constipation
Diarrhea
Gas
Bloating
Irritabilty
Sinus Problems/Allergies
Asthma
Menstrual Problems
Bladder Trouble
Ringing in the Ears
Nervousness
Dizziness
Weight Trouble
Pain/Tension/Numbness In:
Neck
Shoulders
Low Back
Legs
Arms
Hands
Other: (Please Explain)
Which Of The Above Bothers You The Most?
How Long Have You Been Bothered By This Condition?
Describe How It Feels Or Affects You When It Is At It's Worst.
Does This Cause You To Be:
Moody
Irritable
Lose Sleep/Not Sleep Well
Restricted On Daily Activities
Does This Affect Your Work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at the end of the day
Unable to work for long hours
Does This Affect Your Life:
Lose Patience with Spouse or Kids
Restricted Household Duties
Hinders ability to exercise or participate in sports
Interferes with ability to participate in hobbies or other desired activities
There are several alternatives available for you. Please check the item most appropriate for you.
I would like to come to the Doctor’s office for a free consultation with the Doctor.
I would like the Doctor to call me to discuss my health problems before making an appointment.
Preferred Appointment Date & Time
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Do You Have Health Insurance?
Please Choose
Yes
No
Insurance Information
_____________________________________________________________________
Who Is Your Provider?
*
UPMC
Highmark
Medicare
Blue Cross / Blue Shield
Aetna
CIGNA
United Health Care
Health America
No Insurance
Other
Other (Please Explain):
Policy Number:
Insured Name:
_____________________________________________________________________
I understand that I can come into AMWA for a free, no obligation consultation with the Doctor to discuss any of the problems on this form and I hold AMWA harmless.
*
Yes
No
E-Signature
*
First
Last
Powered by
EMF
Form Builder
Report Abuse
