PATIENT!REGISTRATION!!
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- Job Robinson
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1 PATIENTREGISTRATION ChartNumber: PatientName DateofBirth MailingAddress City State ZipCode MaritalStatus(CircleOne)SMWDSex(CirlceOne)MF HomePhone CellPhone WorkPhone SocialSecurityNumber H H EthnicGroup(circleone)NonHHispanic/Hispanic Race SpouseName(Parent/Guardian,ifminor) SpousePhone EmergencyContact,NOTlivingwithyou Relationship Phone# PrimaryCareMD ClinicName ReferringMD ClinicName Wewillneedtoobtaincopiesofyourinsurancecard(s)andaphotoID PrimaryMedicalInsurance ID: Group# Policyholder DateofBirth(forpolicyholder) SecondaryMedicalInsurance ID: Group# Policyholder DateofBirth(forpolicyholder) Is#condition#auto,#liability,#or#Work#Comp#related?YorNDateofInjury: **Pleaseseethebacktosupplytheinjuryclaiminformation**
2 Worker scompensationclaiminformation Allfieldsrequiredinordertoproperlyfileaclaimtoyourinsurance **Yourhealthinsurancewillneedtobeobtainedaswell** InsuranceCompanyName Address City State ZipCode Claim# BodyPartInjured ClaimAdjusterName Phone# Fax# QRCName Phone# Fax# Automobile/LiabilityClaimInformation Allfieldsrequiredinordertoproperlyfileaclaimtoyourinsurance **Yourhealthinsuranceinformationwillneedtobeobtainedaswell** InsuranceCompanyName Address City State ZipCode Claim# BodyPartInjured Stateinwhichaccidentoccurred ClaimAdjusterName Phone# Fax# Whatisyourmainsymptomandhowlonghaveyouhadthissymptoms? Height: Bloodpressure: Weight: Heartrate: Recentweightgain/loss? Dominanthand(CircleOne) Right Left
3 ReviewofSymptoms HEENT Neurologic Endrocrine GI Skin Musculoskeltal Hematology/ Lymphatic Headaches Tremors Excessive Nausea Rashes JointPain Swollen Chills DizzySpells Thirst Vomiting Boils NeckPain Glands Fever Numbness Fatigued Abdominal Itching BackPain Blood Blurred Tingling TooHot Pain Clotting Vision TooCold Heartburn Problems Prolonged wound oozing Genitourinary Urine Retention Painful Urination Urinary frequency Respiratory Wheezing Frequent Coughing Shortnessof Breath PASTMEDICALHISTORY(Pleasecheckanyofthefollowingmedicalproblemsyouhaveorhavehad) General Lung Psychological Neurological Blood GI Cardiovascular GU Other Cancer: Arthritis Lupus Thyroid problem Diabetes Osteoporosis Fibromyalgia CarpalTunnel Asthma Pneumonia Emphysema Tuberculosis Anxiety Bipolar Disorder Depression Schizophrenia Stroke Braintumor Headaches Backinjury Neckinjury Headinjury Seizure Epilepsy Parkinson Disease Multiple Sclerosis Anemia BloodClots Previous Transfusion Bleeding Problems Hepatitis GERD Heartburn Liver disease Colitis Ulcers HeartAttack Hypertension High Cholesterol Atrial Fibrillation Pacemaker Carotid Disease Coronary ArteryDisease Kidney Problem Kidney Stones Urinary Tract Infection Bladder Problem Prostate Problem PertinentImagingStudies Date FacilityName What Have Report? Have Report? MRI CT Discogram Xrays/FlexionandExtension PreviousTreatmentsforthisproblem PastSurgicalHistory Haveyouhadprevioussurgeryforthisproblem?(CircleOne)YesNo IfYes,howlongago? When Where Surgeon Whatsurgery Help? ConservativeTherapy Check Modality Where Dates/howlong Result PhysicalTherapy Chiropractictherapy Injections Other
4 SocialHistory Children(Living) Yes No IfYes,howmany Doyoucurrentsmoke? Yes No IfYes,howlongandhowmanypacksdaily? Ifyouquitsmoking,whendidyouquit? DoyoucurrentlyconsumeAlcohol? Yes No Socially Howmuchdoyoudrinkdaily? FamilyHistory Alive Dead Age MedicalProblems/causeofdeath Father Mother Other Symptoms Pleaserateyoursymptomsfrom1(verymild)to10(verysevere) Pain Numbness Weakness Describeyour Constant Intermittent Main Symptoms Durationof thesymptoms Bladder/bowel None Once Continuous Since: On/Off incontinent Howfarcan Walking Blocks Unableto youwalk? notlimited walk Other symptoms
5 Circlewhatbestdescribeyoursymptomsanddrawonthedrawingofthebodythelocationsofyour symptomsasbelowcodingshows. ACHE>>>>>NUMBNESSbbbbbbbTINGLING000000BURNINGXXXXXXXSTABBING//////// FOROFFICEUSE: Motor Refl Path Prioprioception/others RUE D B T G L B T BR Hoffman LUE D B T G L B T BR Hoffman RLE Q H G TA EHL Ptl Ach BabinskibSLR LLE Q H G TA EHL Ptl Ach BabinskibSLR CN IIIII/IV/VIVVIIVIIIIXbXXIXII MS AAOx3GSC15SpeechDementia Coor FNFBalanceRomberg PatientsSignature: DoctorsSignature:
6 MEDICATIONLIST PatientName: DOB: Phone# PharmacyName: City: Pharmacy# Date Medication Dose Frequency Allergies:
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PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
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Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
More informationPatient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
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Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
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Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
More informationABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
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Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
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PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s)
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3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
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