PATIENT REGISTRATION FORM

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1 PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION (PLEASE USE FULL LEGAL NAME, NO NICKNAMES) LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: ADDRESS: DOB: SOCIAL SECURITY: EMPLOYERS NAME AND ADDRESS: REFERRING PHYSICIAN: EMERGENCY CONTACT: PCP: PHONE: PHARMACY (AND GENERL LOCATION): PHONE: RACE (CIRCLE ONE): AMERICAN INDIAN/ALASKAN NATIVE ASIAN BLACK/AFRICAN AMERICAN NATIVE HAWAIIN PACIFIC ISLANDER WHITE/CAUCASION ETHNICITY (CIRCLE ONE): NON-HISPANIC/LATINO CUBAN MEXICAN/AMERICAN OTHER HISPANIC/LATINO PEURTO RICAN PREFERRED LANGUAGE (CIRCLE ONE): ENGLISH SPANISH OTHE: RESPONSIBLE PARTY/PRIMARY INSURED INFORMATION (PERSON RESPONSIBLE FOR PAYING THIS BILL) RELATIONSHIP TO PATIENT: SELF SPOUSE PARENT OTHER: LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: ADDRESS: DOB: SOCIAL SECURITY: INSURANCE INFORMATION (ALSO, PLEASE ALLOW RECEPTIONIST TO PHOTOCOPY YOUR INSURANCE AND ID CARD) PRIMARY INSURANCE: PPO POS HMO POLICY ID NUMBER: GROUP NUMBER: SECONDARY INSURANCE: PPO POS HMO POLICY ID NUMBER: GROUP NUMBER:

2 PATIENT NAME: DOB: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any Medical service or visit, Lab testing, X-ray, EKG, and any other Screening service or Diagnostic testing ordered by the physician or the physician s staff. I understand and agree it is my responsibility and not the responsibility of the Physician or Clinic to know if my insurance will pay for my Medical service or visit, or Lab testing, X-ray, EKG, or any other Screening service or Diagnostic testing ordered by the physician or the physician s staff. I understand and agree it is my responsibility to know if my insurance has a deductible, co-payment, co-insurance, out of network amount, usual and customary limit, or any other type of benefit limitation for the services I receive, and I agree to make full payment. I understand and agree it is my responsibility to know if my PCP choice has been processed by my Insurance Company or plan. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payment. Signature: Date: Responsible Party Name: RECEIPT OF NOTICE OF PRIVACY PRACTICES

3 WRITTEN ACKNOWLEDGEMENT FORM I,, have received a copy of the Notice of Privacy Practices. Signature of Patient: Date: Signature of Guardian: Date: DISCLOSURES AND CONSENTS

4 AUTHORIZATION TO RELEASE MEDICAL RECORDS

5

6 Patient Form ptid=20& code=newptf... Page 1 of 3 4/9/2013 PATIENT MEDICAL QUESTIONNAIRE Patient Name: PatientTest DOB: Age: 26 year Acc #: TP7263 Contact: No Known Past Medical History PAST MEDICAL HISTORY High Blood Pressure Kidney Failure Stroke Others: Diabetes Heart Disease Lung Disease High Cholesterol Level Liver Disease Asthma Bleeding Disorder Hepatitis Poor Leg Circulation Clotting Disorder Immune Deficiency Aneurysms Cancer Varicose Veins Stomach Ulcer Past Medical History Notes: No Known Surgical History SURGICAL HISTORY SR. NO. AILMENT SINCE PHYSICIAN HOSPITAL Surgical History Notes: No Known Family History FAMILY HISTORY Family History Problems Family History Notes: No Known Drug Allergy ALLERGIES Sr. No. Allergies Reaction No Known Current Medication Sr. No. Drugs CURRENT MEDICATION Sr. No. Drugs

7 Patient Form ptid=20& code=newptf... Page 2 of 3 4/9/ Current Medication Notes: GENERAL Education Grade School High School College Post-Graduate Vocational Training Involved in any legal proceedings or lawsuits No Yes Are you or is there a chance you could be pregnant No Yes FAMILY Marital Status single married divorced widowed has children of unknown marital status EMPLOYMENT Working currently? No Yes Current Occupation If not, when worked last? Applying for disability? No Yes Currently on disability or workman s comp? No Yes Exposure to toxins/poisonous substances at work No Yes SOCIAL HISTORY HABITS Alcoholic beverages? No Yes If yes,frequency of Alcoholic beverages 1 drink/day 2-3 drinks/day 3-4 drinks/day 4-5 drinks/day More than 6 drinks/day If Yes, then how many years? Smoking No 1/4 PPD 1/2 PPD 1 PPD 1 and 1/4 PPD 1 and 1/2 PPD 2 PPD More than 2 PPD Smoked in the past? No Yes How many years did you smoke? Non prescription drug use? No Yes If yes, frequency of non precription drug use Drug or substance abuse? No Yes If yes,frequency of drug abuse Participation to detoxification or rehabilitation No Yes CONSTITUTIONAL SYMPTOMS/GENERAL fever chills malaise/fatigue recent weight changes changes in appetite appearance any kind of disability EARS, NOSE, MOUTH and THROAT hearing loss/ringing bleeding nose sore throat sensation of a lump in the throat swollen glands in neck sinus problems EYES corrective lenses/contacts changes in vision no blurred vision double vision glaucoma RESPIRATORY cough shortness of breath asthma CARDIOVASCULAR high blood pressure pedal edema arrhythmia REVIEW OF SYSTEM GASTROINTESTINAL abdominal pain nausea vomiting diarrhea heartburn indigestion reflux change in bowel habits bowel incontinence constipation swallowing difficulty GENITOURINARY painful urination excessive night time urination urinary frequency hesitancy force of stream UROLOGY weak urine stream frequent urination kidney stones MUSCULOSKELETAL arthritis back pain / injuries muscle pain claudication joint pain / swelling numbness or tingling sensation PSYCHIATRIC depression manic schizophrenia ALLERGIES medications asthma latex previous diagnosis of allergic skin diseases tuberculin tests vasomotor rhinitis family history of allergic disease migraine headaches triggered by allergies other HEMATOLOGIC / LYMPHATIC anemia easy bruising/bleeding slow to heal after cuts deep vein thrombosis ENDOCRINE thyroid disease diabetes heat/cold intolerance excessive urination excessive thirst changes in hair nocturia SKIN rash

8 Patient Form ptid=20& code=newptf... Page 3 of 3 4/9/2013 heart attack phlebitis PND heart problems chest pain or discomfort murmur inability to walk up one flight of stairs NEUROLOGIC weakness numbness seizure head injury headaches stroke dizziness convulsions or seizures paralysis or tremors redness dryness INTEGUMENTARY change in skin color itching rashes varicose veins TOP

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