NEW PATIENT INFORMATION
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- Lorraine Melton
- 6 years ago
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1 NEW PATIENT INFORMATION Name Female Male Social Security # Date of Birth Age Address Apt # City State Zip Address Cell Phone # Home Phone # Work Phone # Marital Status Married Divorced Separated Widowed Single Whom may we thank for referring you? Do you have health benefits with your employer? Your Employment Status Full-time Part-time Self-employed Retired t employed Name of Employer Phone Address City State Zip Name of Primary Insurance Company Payor Network Effective Date of Coverage Type of Health Plan HMO PPO POS Self-funded Traditional t Sure Policy # Group # Policy Holder s Name Are you covered by health benefits from your spouse or another party? Subscriber s Name Name of Secondary Insurance Company Payor Network Effective Date of Coverage Type of Health Plan HMO PPO POS Self-funded Traditional t Sure Policy # Group # Information About Your Spouse / Significant Other Relationship to you Spouse Parent Other Name Phone Social Security # Date of Birth Address Apt # City State Zip Continue to other side.
2 Employment Status of Spouse / Significant Other Full-time Part-time Self-employed Retired t employed Name of Employer Phone Address City State Zip Guarantor Information (who is financially responsible for the bill?) Relation of the Person to You Name Phone Social Security # Date of Birth Address Apt # City State Zip Emergency Contact Information Name of Emergency Contact Phone # Relationship to You Your Primary Care Physician Name Phone Address Apt # City State Zip I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I have read all the information and have completed the above answers. I certify that I have disclosed all sources of health benefit coverage and that this information is true and correct to the best of my knowledge. I will notify you of all changes. n-covered Items or Services: I have been informed that the items or services listed above may not be covered by insurance and that non-coverage does not mean that I should not receive the items or services. I have been informed that a good faith estimated cost of such items or services is $, but I understand that the items or services could actually cost more or less than this amount. I elect to receive the non-covered items or services and agree to be personally and fully responsible for payment. I understand that you may be contacting my insurance provider and / or employer or the insurance provider and / or employer of my spouse or significant other for the purpose of insurance and benefit verification, and I authorize these contacts. I understand that my health information will be kept confidential and I have been given and hereby acknowledge receipt of the tice of Privacy Practices of Barix Clinics. Signature Date Parent s signature if the patient is a minor
3 PATIENT MEDICAL HISTORY Date: Name: Age: Date of Birth: Gender: Female / Male ALLERGIES: Are you allergic to any medications? If yes, list the medications and describe the reaction below: Medication Reaction Are you allergic to any foods? If yes, list the foods and describe the reaction below: Food Reaction Do you have any other allergies? (dust, mold, weeds, etc.) If yes, please list the substances and describe the reaction below: Substance Reaction Are you allergic to latex products? (example: foam rubber, tennis shoes, balloons)
4 MEDICATIONS: Have you or are you currently taking any of the following types of medications: Anti-Depressant? Anti-Hypertension? Coumadin / Heparin? Insulin? Oral Hypoglycemic? Steroids within the last 6 months? Over the counter? HERBAL PRODUCTS / SUPPLEMENTS: Do you use any of the following? Product Dose Frequency St. John s Wort Kavakava Garlic Ginger Ginkgo Biloba Vitamin K Vitamin E Other Please list any medications you are currently taking (prescribed or over the counter): Drug Dose Frequency Why
5 SUBSTANCE USE: How Much # of Years Quit Y/N Do or have you smoked? Do you or have you drank alcohol? Do you or have you used marijuana? Do you or have you used other drugs? SURGERY HISTORY: Have you had any stomach and/or abdominal surgeries? If yes, please describe below: Surgery Year Complications or Problems Have you had any other surgeries? If yes, please describe below: Surgery Year Complications or Problems ANESTHESIA HISTORY: Have you or a family member ever had complications with anesthesia? If yes, please describe:
6 BREATHING & LUNG HISTORY: Do you have any of the following breathing and/or lung problems? Asthma? Emphysema? COPD? Pneumonia? Cough? Snoring? Daytime fatigue? Seasonal sinus problems? Year round sinus problems Tracheostomy Do you have any difficulty breathing laying down? Do you need extra pillows to help you breathe during sleep? If yes, how many pillows? Do you ever wake up short of breath? Have you ever been diagnosed with Sleep Apnea? Are you on a C-PAP/BIPAP? If yes, what is the setting? Do you experience shortness of breath: At rest? After any exertion? While climbing stairs? Do you have any breathing problems that interfere with everyday activity? If yes, please describe:
7 HEART & CIRCULATORY SYSTEM: Do you have or have you had any of the following heart and/or circulation problems: Anemia? Bleeding Problems? Blood clot Lungs? Blood clots Legs? Chest pains? Congestive heart disease? Edema Feet? Edema Hands? Heart attack (MI)? Heart Murmur? High blood pressure? Low blood pressure? Irregular heart beat? Palpitations? Sickle Cell? Varicose veins? Dizziness? Do any of these problems affect your everyday activity? If yes, how? Have you ever been under the care of a Cardiologist If yes, physician s name: Telephone #:
8 MUSCULOSKELETAL & NEUROLOGICAL SYSTEMS: Do you have any of the following problems? Back pain? Hip pain? Knee pain? Joint problems? Joint stiffness and pain? Arthritis? / Osteoarthritis Gout? Weakness / fatigue? Seizures? Numbness / tingling? Carpal tunnel? Headaches? / Migraines? Major Motor Vehicle Accident? Any Physical Disability? Stroke? Multiple Sclerosis? Are you able to walk on your own? If not, do you use a: cane walker brace wheelchair motorized scooter Do you exercise? Type of exercise # minutes/time #times/week
9 STOMACH & DIGESTION HISTORY: Do you have any of the following stomach, digestion, intestinal, colon, or related problems: Heartburn? Trouble swallowing? Ulcers? Hiatal Hernia? Gall bladder? High cholesterol? Hemorrhoids? Hepatitis? Liver Disease? Colitis? Diverticulitis? Crohn s Disease? Chronic history of nausea/vomiting? Chronic history of constipation? Chronic history of diarrhea? Bloody/black stool? Are you diabetic? If yes, treated with: Diet Medication (Pills) Insulin injections Do you check your blood sugar at home? If yes, how often? Last reading: Did you have gestational diabetes while pregnant? / NA
10 URINARY TRACT & REPRODUCTIVE SYSTEM Do you have any of the following problems? (Female only) Fertility problems? Irregular periods? periods? Cysts in ovaries? / Polycystic Ovary Syndrome? Post menopausal? Endometriosis? Lose urine when you cough or sneeze? Hysterectomy? (Male or Female) Urinary tract infections? Bloody urine? Frequent urination? Difficulty urinating? Kidney Problems? Kidney Stones? (Male Only) Prostate problems? OTHER MEDICAL HISTORY: Do you have or have you had any of the following general problems Skin rashes/itching? Open or draining sores? Major dental, vision, hearing problems? Recent hair loss? Hyperthyroidism / Hypothyroidism? History of cancer?
11 FAMILY HISTORY Do any immediate (mother, father, grandparents, siblings) family members have any of the following medical problems (cancer, high blood pressure, diabetes)? If yes, who? Cancer? Diabetes? High Blood Pressure? Cardiac Disease? PSYCHOLOGICAL & SOCIAL HISTORY: Do you or have or have you ever had a problem with any of the following: If yes, year(s) Depression? Hospitalized for depression? Nervous breakdown? Hospitalized for breakdown? Suicidal thoughts? Hospitalized for suicide attempt? Anorexia? Bulimia? Bingeing? Are you currently being seen by a psychiatrist/psychologist? How long have you been overweight? How long have you been at least 100 pounds overweight? How long have you been at your current weight? Do you have a supportive person(s) in your life?
12 RECENT MEDICAL STUDIES DONE: Have you had any of the following medical tests done within the past year: rmal Abnormal Upper GI? Lower GI? Gastroscopy (scope)? Colonoscopy? Pulmonary function tests? EKG? Cardiac workup including stress Chest X-ray? PAP Smear? Mammogram? Annual Check up including blood work DIET HISTORY: Which of these SUPERVISED PROGRAMS have you tried? #Months Attempted Amount loss Personal Physician Medifast / Optifast Weight Watchers Jenny Craig LA Weight Loss Phen-fen Redux Nutri System / Formu 3 Weight Loss Clinic Curves Other Amount regained Which of these PERSONAL PROGRAMS have you tried? #Months Attempted Amount loss Fasting Slim Fast Deal-a-Meal Lo-cal/Low fat diets Diet Pills Other Amount regained RN / LPN / MA: Date:
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WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
More informationPatient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
More informationPATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (PLEASE FILL OUT COMPLETELY) ****************************************************************************** LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: PHONE # S: HOME:
More informationBariatric Patient Registration / /
Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager
More informationName (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:
SCREENING APPLICATION NOTE: THIS APPLICATION MUST BE COMPLETED BEFORE YOU CAN ENROLL IN THE NEW DIRECTION (ND) SYSTEM. PLEASE ANSWER EVERY QUESTION. PLEASE PRINT CLEARLY. Date: Name (Last Name, First Name):_
More informationWeight loss surgery. Life-changing results.
Weight loss surgery. Life-changing results. Our physician experts and program team is devoted to helping patients overcome obesity and reclaim the life, health and future you deserve. Minimally invasive
More informationPlease complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
More informationNAME NAME ADDRESS ADDRESS. PHONE PHONE Cell Phone DATE OF BIRTH DATE OF BIRTH OCCUPATION OCCUPATION MARITAL STATUS MARITAL STATUS
PATIENT INFORMATION (please print) SPOUSE OR PARENT INFORMATION NAME NAME _ ADDRESS ADDRESS PHONE PHONE _ Cell Phone E-MAIL _ E-MAIL DATE OF BIRTH DATE OF BIRTH OCCUPATION OCCUPATION MARITAL STATUS MARITAL
More informationPATIENT INFORMATION. Date of Birth: Soc Sec No: Marital Status: Single Married Divorced Widowed. City: State: Zip:
Please complete the following questionnaire and bring it with you to your appointment. It is important to complete this form as accurately as possible, to assist us in providing you with the highest quality
More informationDate First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
More informationDEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
More informationFOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #
FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S
More informationAddress: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
More informationPATIENT REGISTRATION FORM
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: E-MAIL ADDRESS:
More informationTel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
More informationCASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
More informationSUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
More informationDATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
More informationNew Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
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