Valhalla Urgent Care - Valhalla Vitality

Date of Birth *

Phone *

Email address *

Address

Address Line 1

Address Line 2

City

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Gender *

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Allergies to Medication or Food? () *

NKDA (No Known Drug Allergies)
Yes (please specify it below)

Allergy

List any medications you are taking

Do you have a Primary Doctor? *

Yes
No

Please select any gastrointestinal symptoms you are experiencing (select all that apply) *

Please select any respiratory symptoms you are experiencing (select all that apply) *

Please select any eye, ear, nose, and throat/mouth symptoms you are experiencing *

Please select any muscle or skeletal symptoms you are experiencing (select all that apply) *

Description how you are feeling today and what you would like help with? *

Describe where it hurts (if applicable)

Upload Photo of the Affected Area (if applicable)

Drop your file here or click here to upload

How long have you had these symptoms *

Past Medical History: Please check all that apply. *

Past Medical History Other

Have you had a Cardiac Stress Test? *

Past Surgical History *

Surgical History Other

Please list any psychological issues, or diagnosis or concerns. *

Do you take Vitamin Supplements (select all that apply)

Other supplements or nutritional shakes, drinks, chews, tablets etc.

Smoking Cigarettes *

Never
Daily
Occasionally
Former smoker

Vaping *

Never
Daily
Occasionally
Formerly vaping

Alcohol *

Never
Daily
Occasionally

Marijuana use *

never
daily
occasionally
Former smoker

Caffeine consumed daily (Coffee, Tea, Soda-pop etc.)? *

1-2 drinks
3-4 drinks
More than 5
none

Energy drinks consumed daily (Red Bull, Monster, Rockstar, 5-Hour Energy, Pre-Workout etc.)?

1-2
3-4
More than 5
none

Sexual Health History (please select all that apply) *

Females: Do you menstruate regularly?

Yes
No

Female Birth Control Use

Female History of an abnormal pap-smear?

Yes
No

Female Hormone Therapy? (please list)

Male Only: Date of your last Prostate Exam

Male Testosterone Treatments (please list)

Describe any physical limitations, injuries or assistive device usage such as supportive brace, cane, walker etc.

Please report your vital signs if they are available

Oxygen Saturation

Blood Pressure

Body Temperature

Preferred Pharmacy (e.g., Walgreens, CVS, Local Pharmacy Name)

Pharmacy Name

Pharmacy Address

Pharmacy Contact Number

How did you hear about us? *

Please tell us who referred you, we want to thank them!!

Please Complete this form so we can provide excellent care for you

Please report your vital signs if they are available

Preferred Pharmacy (e.g., Walgreens, CVS, Local Pharmacy Name)

OUR COMPANY

OFFICE HOURS