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Patient Registration Form
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Step
1
of 4
PATIENT INFORMATION
Name
*
First
Middle
Last
Checkboxes
Mr
Mrs
Checkboxes
Miss
Ms
Email Address
*
Is your name legal?
Yes
No
If not, what is your legal name?
Former Name
Birth Date
*
Age
*
Sex
*
Male
Female
Street Address
*
Cell Phone
*
Home Phone
P.O Box
City
State
Zip Code
Occupation
Employer
Work Phone
IN CASE OF EMERGENCY
Name of local friend or relative
(not living at same address)
Relationship to patient
Home Phone
Cell Phone
INSURANCE INFORMATION
( Please give your insurance card to the receptionist )
PREFERRED PHARMACY
Name
Location
Phone
Fax
CURRENT MEDICAL PROBLEMS
1
2
3
4
5
6
7
8
9
10
ALLERGIES
Allergies
Reactions
Next
CURRENT MEDICATION LIST
Name
Strength
Direction
Prescribed By
Name (copy)
Strength (copy)
Direction (copy)
Prescribed By (copy)
Name (copy) (copy)
Strength (copy) (copy)
Direction (copy) (copy)
Prescribed By (copy) (copy)
Name (copy) (copy) (copy)
Strength (copy) (copy) (copy)
Direction (copy) (copy) (copy)
Prescribed By (copy) (copy) (copy)
PAST MEDICAL HISTORY
Childhood Illnesses
Chronic Illnesses
Last Eye Exam
Last Dental Exam
Accidents ( with dates )
Surgeries / Procedures ( with dates )
Other hospital stays ( with dates )
Any problem with Anesthesia?
Yes
No
If yes explain
Specialist you currently see
Next
FAMILY HISTORY
Family Member
Medical Issues
Age
Father
Paragraph Text
Paragraph Text (copy)
Mother
Paragraph Text (copy)
Paragraph Text (copy) (copy)
Siblings
Paragraph Text (copy) (copy)
Paragraph Text (copy) (copy) (copy)
Paternal Grandmother
Single Line Text
Single Line Text
Paternal Grandfather
Single Line Text (copy)
Single Line Text (copy)
Maternal Grandmother
Single Line Text (copy) (copy)
Single Line Text (copy) (copy)
Maternal Grandfather
Single Line Text (copy) (copy) (copy)
Single Line Text (copy) (copy) (copy)
SOCIAL HISTORY
Do you drink alcohol?
Yes
No
If yes, how much?
Are you sexually active?
Yes
No
If yes, what form of contraception do you use?
Do you consume caffiene?
Yes
No
If yes, how much?
Diet
Balanced
Vegetarian
Diabetic
Low Salt
Low Fat
Low Carb
Others
Have you been in an abusive relationship?
Yes
No
If yes, how much? (copy)
Are you afraid of your partners?
Yes
No
If yes, how much? (copy) (copy)
Education
High School
Some School
College Degree
Trade School
Others
Do you do some form of exercise daily?
Yes
No
If yes, how much?
Marital Status
Single
Married
Divorced
Widowed
Others
Place of Birth ( City, State )
Have you lived abroad for more than a month?
Yes
No
If yes, how much?
Do you wear seatbelts?
Yes
No
If yes, how much?
Do you smoke or chew tobacco?
Yes
No
If yes, how much?
Do you use recreational drugs?
Yes
No
If yes, how much?
WOMEN'S HEALTH
Date of your last menstrual period
Typical duration ( in days )
# of Total Pregnencies
Are you periods regular?
Yes
No
# of Full Term Births
Flow
Normal
Light
Heavy
Others
# of Premature Births
How many days apart are periods?
# of Abortions- induced
Age at onset of period
# of Miscarriages
Age at cessation of periods
# of Ectopic Pregnancies
Have you ever had any abnormal pap smears?
# of Multiple Birth Pregnancies
Have you ever been diagnosed with any STD's?
# of Living Children
Next
HEALTH MAINTENANCE
Hep A
Hep B
Flu Vaccine
Pneumonia Vaccine
Tuberculosis
Positive PPD
TdaP (Tetanus, Diptheria and Pertussis}
Meningococcal
MMR
Zostavax
Bone Density Scan
Breast Exam
Cardiac Stress Test
Colonoscopy
EKG
Hearing Exam
Mammogram
Eye Exam
Pelvis Exam
Pap Smear/GYN
Physical Exam
REVIEW OF SYMPTOMS
( Check all that apply )
Skin
Skin diseases
Gastrointestinal
Abdominat discomfort
Indigestion
Nausea
Vomiting
Constipation
Diarrhea
Blood in staal
Ulcers
Change in bowel habits
Unexplained weight gain/loss
Hemorrhoids
Gall bladder disease
Colitis
Genitourinary (Female & Male)
Frequent urination
Kidney diseases
Kidney stones
Difficulty urinating
Endocrine
Diabetes
Thyrold disease
Musculoskeletal
Arthritis
Low back problems
Gout
Infectious Disease
Venereal diseases
Hepatitis or Jaundice
TB
Rheumatic fever
Eye
Eye diseases
ENT
Hay Fever
Head or Neck
Respiratory
Shortness of breath
Asthma
Bronchitis
Pneumonia
Persistent cough
Cardiovascular
High blood pressure
Heart disease
Chest pain
Swollen ankles
Palpitations
Lightheadedness
Neurological
Headache
Psychiatric
Anxiety
Depression
Alcohol abuse
Drug abuse
Hematologic/Oncotogic
Cancer(s}
Blood disorders
Anemia
OTHER
Do you have an advanced directive or living will?
Yes
No
Notes
Date
Reviewed By
Date
Submit
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