Patient Registration & Medical History Packet

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Patient Registration

Please print and complete all entries.

Date

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Patient Name (Last -- First -- Middle Initial)

Please complete this field.

Address

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City, State

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Zip

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Home Phone

Please enter a 10-digit phone number (numbers only).

Cell Phone

Please enter a 10-digit phone number (numbers only).

Patient Date of Birth

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Patient SSN

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Sex

Male

Female

Please select an option.

Marital Status

Single

Married

Other

Please select an option.

If Other, specify

Please complete this field.

Pharmacy

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Pharmacy Address (Street Address - City - State - Zip)

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Employer

Please complete this field.

Consent to Receive Appointment Reminder

Yes

Please select an option.

Cell Phone

Please enter a 10-digit phone number (numbers only).

Please complete this field.

Insurance Information

Insurance Name

Please complete this field.

Address (Street - City - State - Zip)

Please complete this field.

Phone

Please enter a 10-digit phone number (numbers only).

Group Number

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ID Number

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Employer

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Employer Phone

Please enter a 10-digit phone number (numbers only).

Secondary Insurance Name

Please complete this field.

Address (Street - City - State - Zip)

Please complete this field.

Phone

Please enter a 10-digit phone number (numbers only).

Group Number

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ID Number

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Employer

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Employer Phone

Please enter a 10-digit phone number (numbers only).

Primary Doctor/Family Doctor

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Referring Doctor

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In Case of Emergency, please contact

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Relationship

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Phone Number

Please enter a 10-digit phone number (numbers only).

Assignment and Release

I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

Please complete this field.

Authorization to release health information to:

Name(s)

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Address

Please complete this field.

City, State

Please complete this field.

Zip

Please complete this field.

Home Phone

Please enter a 10-digit phone number (numbers only).

Daytime Phone

Please enter a 10-digit phone number (numbers only).

Dates of Service - From

Please complete this field.

Dates of Service - To

Please complete this field.

Authorization Expires: Never (unless otherwise noted this authorization will remain in effect one year from the date signed)

Please mark this checkbox.

Authorization Expires Date

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Release the following information:

All Records

Please mark this checkbox.

Chart Notes

Please mark this checkbox.

Radiology Reports

Please mark this checkbox.

Operative Reports

Please mark this checkbox.

History & Physicals

Please mark this checkbox.

Release of Information

I understand that:

Once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.

I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524).

My records are protected and cannot be disclosed without written permission.

This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.

Date

Please complete this field.

If signed by Legal Representative, Relationship to Patient

Please complete this field.

Patient Medical History

Date

Please complete this field.

Patient Name (Last -- First -- Middle Initial)

Please complete this field.

Allergies

NONE/No Known Allergies

Please mark this checkbox.

Adhesive Tape

Please mark this checkbox.

Anesthesia

Please mark this checkbox.

Aspirin

Please mark this checkbox.

Codeine

Please mark this checkbox.

Dairy Products

Please mark this checkbox.

Iodine/Shellfish/Contrast Dye

Please mark this checkbox.

Latex

Please mark this checkbox.

Morphine

Please mark this checkbox.

Penicillin

Please mark this checkbox.

Sulfa Drugs

Please mark this checkbox.

Wheat

Please mark this checkbox.

Other

Please complete this field.

Family History

Please indicate if any of your immediate relatives have had any of the following (Mother / Father / Sibling).

Anesthesia Problems - Mother

Please complete this field.

Anesthesia Problems - Father

Please complete this field.

Anesthesia Problems - Sibling (Brother/Sister)

Please complete this field.

Arthritis - Mother

Please complete this field.

Arthritis - Father

Please complete this field.

Arthritis - Sibling (Brother/Sister)

Please complete this field.

Cancer (where exactly) - Mother

Please complete this field.

Cancer (where exactly) - Father

Please complete this field.

Cancer (where exactly) - Sibling (Brother/Sister)

Please complete this field.

Diabetes - Mother

Please complete this field.

Diabetes - Father

Please complete this field.

Diabetes - Sibling (Brother/Sister)

Please complete this field.

Heart Problems - Mother

Please complete this field.

Heart Problems - Father

Please complete this field.

Heart Problems - Sibling (Brother/Sister)

Please complete this field.

Hypertension - Mother

Please complete this field.

Hypertension - Father

Please complete this field.

Hypertension - Sibling (Brother/Sister)

Please complete this field.

Stroke - Mother

Please complete this field.

Stroke - Father

Please complete this field.

Stroke - Sibling (Brother/Sister)

Please complete this field.

Thyroid Disorder - Mother

Please complete this field.

Thyroid Disorder - Father

Please complete this field.

Thyroid Disorder - Sibling (Brother/Sister)

Please complete this field.

Social History

Occupation

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Retired

Please mark this checkbox.

Disabled

Please mark this checkbox.

Disabled reason

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Do you drink alcohol?

Yes

Please select an option.

If yes, how often

Daily

Weekly

Infrequently

Recovering Alcoholic

Please select an option.

Do you use tobacco?

Yes

Please select an option.

Smoke

Please mark this checkbox.

Packs per day

Please complete this field.

Chew

Please mark this checkbox.

Surgical History

Please list any hospitalizations, surgeries, fractures or major illnesses you have had (Type of Surgery / Year or Date / Doctor / Location).

Surgical History (Type of Surgery / Year or Date / Doctor / Location -- one entry per line)

Please complete this field.

Medical History

Have you ever had any of the following?

NONE of the problems listed

Please mark this checkbox.

allergies

Please mark this checkbox.

anemia

Please mark this checkbox.

arthritis conditions

Please mark this checkbox.

asthma

Please mark this checkbox.

arterial fibrillation

Please mark this checkbox.

bleeding problems

Please mark this checkbox.

BPH

Please mark this checkbox.

CAD coronary artery disease

Please mark this checkbox.

cancer

Please mark this checkbox.

cardiac arrest

Please mark this checkbox.

celiac disease

Please mark this checkbox.

chest pain

Please mark this checkbox.

CHF congestive heart failure

Please mark this checkbox.

chronic fatigue syndrome

Please mark this checkbox.

depression

Please mark this checkbox.

diabetes

Please mark this checkbox.

drug/alcohol abuse

Please mark this checkbox.

erectile dysfunction

Please mark this checkbox.

fibromyalgia

Please mark this checkbox.

Gerd

Please mark this checkbox.

heart disease

Please mark this checkbox.

high cholesterol

Please mark this checkbox.

hyperinsulinemia

Please mark this checkbox.

hyperlipidemia

Please mark this checkbox.

hypertension

Please mark this checkbox.

hypogonadism male

Please mark this checkbox.

hypothyroidism

Please mark this checkbox.

infection problems

Please mark this checkbox.

insomnia

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irritable bowel syndrome

Please mark this checkbox.

kidney problems

Please mark this checkbox.

menopause

Please mark this checkbox.

migraines/headaches

Please mark this checkbox.

neuropathy

Please mark this checkbox.

onychomycosis

Please mark this checkbox.

organ injury

Please mark this checkbox.

osteoporosis

Please mark this checkbox.

pulmonary embolism/blood clot in legs

Please mark this checkbox.

seizure disorders

Please mark this checkbox.

shortness of breath

Please mark this checkbox.

sinus conditions

Please mark this checkbox.

stroke

Please mark this checkbox.

syndrome X

Please mark this checkbox.

tremors

Please mark this checkbox.

wheat allergy

Please mark this checkbox.

Medications

List any medications you are currently taking (please include over the counter medications). Please print legibly -- no cursive please.

Medications (Medication / Dosage / Prescribing Doctor -- one medication per line)

Please complete this field.

Please sign your name in the area below

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