```html Purrfect Physical Therapy - Patient Registration
First Name: Middle Initial: Last Name:
Date of Birth: SSN:
Address Line 1:
Address Line 2:
City: State: Zip Code:
Email: Phone:
User ID:
Password: Re-enter Password:
Current Symptoms:
Past Illnesses: Chickenpox Measles COVID-19 Smallpox Tetanus
Gender: Male Female Other
Vaccinated: Yes No Has Insurance: Yes No
Health Rating:
```