ASTHMA & ALLERGY CENTER
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1 ASTHMA & ALLERGY CENTER Parkersburg. Ripley.Beckley.Logan. CHARLESTON. WV Asthmaweb,com Welcome All of us at the Asthma and Allergy Center would like to welcome you as a new patient to our office. Please read the Office Policies Brochure, fill in all six pages of the New Patient Registration & Medical History Form, and bring it with you on your first visit. If you have received this packet in mail and prefer to fill the form on a computer, you'll find it on the New Patient Page of our website: asthmaweb.com. Please print the filled form and bring it with you*. You will need to stop taking any medications that contain antihistamines [such as Claritin, Benadryl, Clarinex, Zyrtec etc.] for a minimum of five days prior to your visit. If your appointment is less than five days away, or you cannot stop the Antihistamines due to severe symptoms, or you are not sure whether the medications you are taking contain anantihistamine **, please call us. You must not stop any other medications you are on that do not contain antihistamines. Please note that a new patient office visit can take up to three hours depending on thetests you may need. If your insurance requires referral to see a specialist please ensure it is obtained prior to your visit date. If you need help with that or have questions about any other aspect of your visit please feel free to call us at We look forward to serving you. Sincerely yours Asthma and Allergy Center *Besides the completed forms, please bring your Govt. issued photo ID (of the responsible person if other than the patient), health insurance and prescription cards, bottles of current medications if you are on more than two or three, and any referral documents or test reports your doctor may have given you. **Many prescription and over the counter medications for cough, colds, allergies, sinus, sleep, mental health, vertigo, motion sickness, nose sprays, eye drops etc. contain antihistamines.
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3 ASTHMA AND ALLERGY CENTER 208 MacCorkle Ave., S.E., Charleston, WV Tel (304) Charleston, Beckley, Parkersburg, Logan, Ripley Patient s Name Age Birthdate Male Female Race/Ethnicity: Caucasian African-American Asian-American Hispanic Native -American Other: Address City State Zip Home Phone Cell Phone S.S. # Employer Work Phone Marital Status: Single Married Widowed Divorced Separated Student? yes no Spouse s Name Spouse s Employer: Spouse s Work Phone Spouse s Work Address: Are any family members patients here? no yes. If yes, who? Name and address of a close relative not living with you: Name Address Home Phone IF PATIENT IS A MINOR: Mother s Name Employer Work Phone Cell Father s Name Employer Work Phone Cell Legal Guardianship: Parents Mother Only Father Only Other: REFERRING PHYSICIAN / PCP INFORMATION: Doctor who referred for consultation: Tel No. Location: Patient s Primary Care Physician: Tel No. Location: PRESCRIPTION CARD INFORMATION: Company Name Card I.D. No. 1 st Your Pharmacy Name: 2 nd Location: Tel No: HEALTH INSURANCE: (You MUST bring your insurance cards with you.) 1st Company Name: Policy No. Eff Dates: from to Policyholder Name & D.O.B. SS#: Rel to Patient: Address : Home #: Work #: Cell #: 2nd Company Name: Policy No. Eff Dates: from to Policyholder Name & D.O.B. SS#: Rel to Patient: Address : Home #: Work #: Cell #: 1A continued
4 Does your insurance require referral or pre-certification to see a specialist? no yes don t know Is treatment of allergies covered by your Insurance? no yes don t know How much is your deductible? $. Is it yearly? half yearly? Is it per person? whole family? Have you met your deductible for this year? no yes In which month does your deductible restart? How did you learn about us? PAYMENT & BILLING POLICIES For Medicare, Medicaid and insurance programs that list us as preferred provider, you are responsible only for the deductible and copayments, which must be paid at check out time. We will submit and follow up the insurance claims. For all other insurance policies, the deductible, copayment and coinsurance must be paid at check out time. We will submit your insurance claim if you wish, but you must follow up with your insurance company. In all cases you are responsible for whole or any part of the bill not covered by insurance. If you are unable to pay as above at check out time, please call in advance or see the receptionist before you see the doctor to make alternate arrangements. We accept Visa / MC / Discover. CONSENTS: With respect to the patient described on this form, for services performed by any medical provider at or on behalf of Asthma and Allergy Center, I agree and give my consent as follows: To conduct medical tests and give medical treatment as per the provider s best judgment. Use this form as authority to submit bills and receive payments from my Health Insurance Companies. To release any or all information and to send medical reports to my Health Insurance Companies, the referring doctor, the primary doctor and any other doctor treating the patient and as described in the Privacy Notice I have received, read and reviewed. To contact me by telephone, or text messages and leave messages on answering machine for test results, missed appointments and appointment reminders at telephone numbers and addresses given above. 5. To act as my agent in obtaining payment from my Health Insurance Companies. 6. To use a copy of this authorization in place of the original. 7. That I will abide by the above Payment & Billing Policies. 8. That I have read and will abide by the above Payment & Billing Policies of Asthma & Allergy Center. I confirm that I have read and I understand the above statements. I affirm that all information given on these papers is true to the best of my knowledge and that I have legal authority to give these consents on behalf of myself / or (Patient Name) Further, I confirm that I have received a copy of the Privacy Notice. Signature of responsible person Date: Witness: Address: SS # Driver s Lic No. FOR OFFICE USE ONLY Written consultation request / Fax response on file Awaiting fax response Privacy Notice given (initials & date) 2A
5 ASTHMA AND ALLERGY CENTER 208 MacCorkle Ave., S.E., Charleston, WV Tel (304) Charleston, Beckley, Parkersburg, Logan, Ripley NEW PATIENT HISTORY Pt. Name.: For what illness are you seeking treatment: Check Major Symptoms: (If none, please Check None) NOSE: Itching Running Sneezing Stuffiness Nosebleeds None EYES: Itching Watering Swelling Redness Dark Circles None EARS: Itching Blocking Infections Fluid in Ears Hearing Loss None THROAT: Itching Voice Loss Infections Hoarseness Post-Nasal Drip None CHEST: Coughing Wheezing Smothering Shortness of Breath Tightness Infections Green/Yellow Sputum Blood in Sputum None HEADACHE: Sinus Facial Pain Tension Migraine Other None SKIN: Hives Eczema Swelling General Itching Rash None ABDOMEN: Nausea Cramps Vomiting Indigestion Diarrhea None GENERAL: Fatigue Feel Sick Infections Weight Loss Poor Appetite None Which of the above are most important to you? Which of the above are currently bothering you? And for how long? When did these problems occur for the first time in your life? Are your symptoms: Constant? In attacks? Seasonal? Recently getting worse? Are you worse in: Jan. Feb. March April May June If attacks: July Aug. Sept. Oct. Nov. Dec. How often do you have them? How long does each last? When did you have the last one? Do you have symptoms all year round? n y Which is your worst season? Spring Summer Fall Winter All year round D.O.B.: If seasonal or in attacks, are you completely clear of symptoms between Signature: MD / PAC spells? n y Date: 1
6 How many chest colds do you average per year? Do you cough, wheeze, feel tight in the chest, or short of breath after exercise? n y Do you cough, smother or wheeze at night? n y Trees Industrial Fumes ACE Inhibitor Air Conditioner Feathers Weather Change Beta Blockers Excitement Weeds Outdoors Ibuprofen Insect Stings Animals Food Odors Exertion Grass Paints, Varnishes Beer/Wine Laughing Hay/Grain Soaps/Detergents Cocktail Shrimp Dampness/Rain Mold/Mildew Cigarette Smoke Potato Chips Fatigue Cosmetics, perfumes Salad bar Cold Air Insecticides Other foods Menstrual Period Temp Change Are there any foods you cannot eat for reason other than taste? If yes, which foods and why? n y Have you had an unusual or severe reaction to insect stings? n y What treatment have you tried for this illness? What helped the most? Do you use nose spray? n y Name of spray? Have you ever taken oral steroids (Prednisone, Medrol, etc.)? n y When was the last time you had a chest x-ray? Sinus x-ray? TB test? What were the results? Have you had allergy tests before? n y When? By whom? What were the main positive reactions? Did you receive allergy injections? n y Did they help? n y If applicable, are you pregnant? n y BirthControl? n y If child, is he/she up-to-date on immunizations? n y Have you ever had pneumonia vaccine? n y Flu vaccine? n y Is patient or any family member allergic to Penicillin or Cephalosporin? n y Signature: MD / PAC Date: 2
7 ENVIRONMENTAL HISTORY How many beds in patient s bedroom? Are there feather pillows in the house? n y Plastic covers on mattress and pillows? n y Mattresses are: Innerspring Waterbed Cotton Polyfoam Other Carpeting in bedroom? Rug Pad? Drapes? Stuffed Animals? Air Conditioning? Upholstered Furniture? Type of Heating System? Electronic Filter? Do you have pets or other animals around the house? n y What kind? In or out of the house? Is the area around your house damp or moldy? n y Is there any mold or mildew growth inside your house? n y Is there anything else around the house you suspect of causing your symptoms? n y Are there any special dusts or fumes where you work? n y Tobacco Use: Never smoked or less than 100 cigarettes in lifetime Current non-smoker: smoked for years average packs/day quit months/years ago Current smoker: 1-3 cig/day ½ -1 pack/day 1-2 packs/day Non-smoker but exposed to second-hand smoke at home or elsewhere? Do you use smokeless tobacco? n y PAST ILLNESSES: Has patient ever had any of the following? Asthma Nasal Polyps Adenoidectomy Hives Bronchitis Sinusitis Tubes In Ears Welts Pneumonia Ear Infections Sinus Operation Eczema Hay Fever Tonsillectomy Nasal Surgery Dermatitis High Blood Pressure Diabetes Heart Disease Tuberculosis Peptic Ulcer Liver Disease Hiatal Hernia Kidney Disease Gastric Reflux Leg Vein Thrombosis Arthritis Any other Illnesses: FAMILY MEDICAL HISTORY (check if yes) Have any BLOOD RELATIVES OF THE PATIENT had any of the following? Bronchial Asthma Hives Migraine Food Allergy Emphysema Hay Fever Sinus Eczema Nasal Polpys Bronchitis Other Allergies Signature: MD / PAC D Date: 3
8 Please list all Hospitali ations with approximate dates and diagnosis. Reason Date List all Surgeries with approximate dates and diagnosis. 1 Surgery Date Diagnosis List all Current Medical Problems other than those you are coming to see us for, with approximate date and treatment you are taking. Problem Date of Diagnosis Treatment List all Current Medications you are taking, including supplements and herbals with approximate dates when started. If more than two, pl bring all current bottles with you. For Allergic Rhinitis / Asthma: Date Started For other illness: Date Started Are there any medications you are allergic to or cannot tolerate for other reasons? n y List all and explain: 4
Richmond Office 4718 National Rd. E. Richmond, IN
You have an appointment at Allergy & Asthma Care at the following address: Richmond Office 4718 National Rd. E. Richmond, IN 47374 765.966.0390 765.966.3343 You can visit our website at www.allergy-asthmacare.com
Patient Name: Date / Time of Appt: at
12422 South 450 East, Suite C, Draper, UT 84020 (801) 553-1900 Fax (801) 553-9995 Patient Name: Date / Time of Appt: at Duane J. Harris, MD and the staff of Intermountain Allergy & Asthma of Draper welcome
Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:
Dr. Bina Joseph Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician: Describe each problem that has led you to seek this allergy evaluation: 1. 2. 3. 4. Drug Allergies:
Medical History Form
Dr. Vivek U. Rao, M.D. 500 Adams Ave., Suite 300 Odessa, TX 79761 Phone: 432.333.3300 Fax: 432.339.3300 Medical History Form Patient Name: DOB: A. CHIEF COMPLAINT: Briefly describe your (or your child
Telephone Number Home: Work: Cell:
Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST
Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
180 Montgomery Street, Suite 2370 San Francisco, CA 94104 Tel: (415) 433-6673 Fax: (415) 433.6063 www.mydrd.com Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor,
1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.
Patient s Name Date of Appointment Date of Birth Referring Physician 1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.
Please Print When Filling Out This Form
Please Print When Filling Out This Form For Office Use Only Patient #: Location: Date of First Appointment: Patient Information Patient s Name: Home: ( ) Address: _ Street City State Zip E- Mail Address:
Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)
Date: How did you hear about us? Patient Name: Internet Physician Referral Date of Birth: Friend Advertisement Patient Email: Referring Physician: Primary Care Physician: _ Age: Reason for visit to allergy
DEVOE ALLERGY & ASTHMA CLINIC Phillip W. DeVoe, M.D., PA
WELCOME TO DEVOE ALLERGY AND ASTHMA CLINIC New Patient Instructions Thank you for choosing DeVoe Allergy and Asthma Clinic for your health care needs. We strive to make your visit as pleasant as possible.
Allergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION
720 W. 34 th Street Suite 200 Austin, Texas 78705 Office (512) 454-5821 Fax (512) 459-9137 PATIENT INFORMATION MRN DR ENTERED VERIFIED Patient Information ( as it appears on insurance card) Last First
SECONDARY INSURANCE Insurance Name Guarantor* *List person or insured name responsible to ensure
DATE: Sec. Initials: PATIENT NAME: (Last) (First) Cell: Home: Work: Email: ADDRESS: (Street) (City) (State) (Zip) Date of Birth: Sex: Male Female Race\Ethnicity: Emergency Contact Name: Phone No.: Family
SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE
SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE BRIEFLY DESCRIBE REASON FOR ALLERGY VISIT. HAVE YOU EVER HAD THE FOLLOWING S: PRESENT PROBLEM YES
Family Allergy Clinic
Please complete and bring these forms with you to your appointment. Patient Information: Family Allergy Clinic First Name: Last Name: Middle Initial: Preferred Name: Sex: Date of Birth: Social Security:
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
Name: Date: How were you referred? Physician Other Self Referral. What problem brings you or your child to this appointment?
Name: Date: How were you referred? Physician Other Self Referral What problem brings you or your child to this appointment? What did the symptoms begin? Are your symptoms getting worse? Circle: Yes or
Name: Date: 1. What is the principal reason for consulting us?
Name: Date: 1. What is the principal reason for consulting us? 2. Circle any of the following that you have had: Sneezing Runny nose Stuffy nose Shortness of breath Phlegm Headaches Watery eyes Swelling
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit. In order to obtain valid and useful skin testing results, you will need to stop the use of
PLEASE DO NOT WEAR FRAGRANCES
Patient s Name: City: State: Zip: Male Female Race: Ethnicity: Language 1st: 2nd: Home Phone: Work Phone: Cell Phone: Email: Occupation: Employer: City: State: Zip: Family Doctor/Pediatrician: City: State:
Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE
Page 1 of 5 Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE NAME: AGE: DATE OF BIRTH: Primary/Referring Physician: Phone #: Other Subspecialists
ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR
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Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F
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New Patient Questionnaire
- - Toda y 's Date: Primary Care Provider's Name: Was a consultation recommended? Primary Clinic: Referring provider's name (if different): Please answer the following questions to facilitate the diagnosis
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(pedi) Patient Name: date of birth:
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PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
New Patient Information & Consents
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Appt Date: Appt Time:
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Welcome to our Office New Patient Information Dme PATIENT'S NAME (PLEASE PRINT) S.S.# I MARITAL. STAlUS SEX BIRTH DATE AGE STREET ADDRESS CITY & STATE ZIP CODE HOME PHONE RACE!LANGUAGE / ETHNICITY PATIENT'S
Date of Birth Sex: M or F Age
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THE ALLERGY AND ASTHMA CLINIC
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PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
CASE 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.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
MEDICAL DATA SHEET For Patients 18 years of age and older
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Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present
BRIEFLY DESCRIBE THE REASON FOR THIS VISIT (what is your main concern or symptom?): CHECK SYMPTOMS YOU HAVE OR HAVE HAD: Nasal Symptoms Past Present Nasal congestion Runny nose Nasal discharge Postnasal
Adult Allergy & Medical History
Adult Allergy & Medical History Ridhu C. Burton, M.D. How did you hear about our office? Referral by another physician Referral by another patient Phonebook listing Internet Ad; Please circle one Google,
NEW PATIENT REGISTRATION FORM
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SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
New Patient Registration
1 New Patient Registration Please Print New Patient Name (Last, First, Middle ) Nickname Maiden / Former Name Male / Female Single / Married / Divorced / Widowed Age Date of Birth Social Security Number
Please call at least 24 hours in advance to cancel any appointment. You may be charged a $20.00 fee for a no call/ no show office visit.
Welcome to the Sleep Disorders Center at Kettering Medical Center. We would like to ask that you fill out the following information before you arrive to the sleep clinic on your scheduled appointment.
List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?
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THE ALLERGY AND ASTHMA CLINIC
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1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
NAME: AGE: ---- Date of Appointment:. ID (For Office Use Only): RETURN VISIT Date of Visit: Main Reason for visit: Reevaluation Family Doctor: Symptoms worse _ New problem _ Yearly follow up _ Follow up/office
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
If you have asthma or use a rescue inhaler please answer the following questions:
Hernia (yr ), Tonsillectomy (yr ), Adenoidectomy (yr ), Bowel (yr ), Lung (yr ), Thyroid (yr ), Arthroscopy (yr ), Other Surgery (yr: ) Dates of Hospitalizations: What Hospital: Previous Tests Done/Approximate
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PATIENT REGISTRATION
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ALLERGY & ASTHMA ASSOCIATES PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS THE PAPERWORK - BRING ALL INSURANCE CARDS
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ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:
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PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME
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1 Name: Address: City: State: Zip: Phone: Email: Date of Birth: Male Female Pregnant Yes No Trimester 1 2 3 SECTIONS: Please select the section(s) that apply to you and complete those sections only 1.
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Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
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HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:
36320 Inland Valley Drive Suite 201 Wildomar, CA 92595 Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: E-mail address: Date of birth: SSN: Would
PATIENT 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:
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
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
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Patient 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:
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
New Pulmonary Patient Questionnaire. Name Age Date. General Medical History
New Pulmonary Patient Questionnaire Name Age Date General Medical History 1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1. Please list any surgeries you have had and their approximate
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
CHISHOLM TRAIL ALLERGY AND ASTHMA PHONE (817) /FAX (817) DUTCH BRANCH ROAD, SUITE 200, FORT WORTH, TX
Today s Date: New Patient Registration and Medical History Patient Name: Nick Name: Address: Apt/Lot: City: State: Zip Code: Home Phone: Cell phone: Email: Is it ok to leave messages on the phone numbers
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Patient Information. Address: Street Apt. # City State Zip. Seasonal Address: (If different than above address) Address: Street Apt.
Page 1 of 6 Patient Information Name: Date of Birth: Age: Address: Seasonal Address: (If different than above address) Address: S.S. #: - - Sex: M F Marital Status: M S D Sep W Partnered Phone: Home (
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Mr. Ms. Mrs. Dr. First MI Last. Zip City State. Zip City State. Zip City State. Zip City State. Mr. Ms. Mrs. Dr. DOB: First MI Last.
1 of 14 2 of 14 3 of 14 Date / / History No.: Patient Information Street Mr. Ms. Mrs. Dr. First MI Last Mailing Phone Date of Birth SS# Occupation Gender M F Marital Status Employer Employer Phone Family
ALLERGY & ASTHMA SPECIALISTS, P.C.
ALLERGY & ASTHMA SPECIALISTS, P.C. Leonard Silverstein, M.D. Ruth L.K. Gold, M.D. Health Questionnaire Jennifer A. Sherman, D.O. Niya Wanich, M.D Patient: D.O.B.: / / Age: Date: / / Height: Weight: Reason
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
FOLSOM 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
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
**No food or beverages are allowed in the exam room**
ALLERGY & ASTHMA ASSOCIATES Neil Feldman, D.O. Rebecca Aul, C.R.N.P. This is to confirm your appointment on: Location: PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS THE PAPERWORK - BRING
Female. Separated. Non-Hispanic/Latino. Unknown
Patient Information Today s Date Patient s Legal Name Other names patient uses Male SSN - - Marital Status Single Ethnicity Hispanic/Latino Married Female Separated Non-Hispanic/Latino Date of Birth /
ALLERGIES (food,latex,other)
MEDICATION LIST NAME: DOB: Main Phone: (CELL or HOME) Initials Consent to Import Medication History I give Dr. Heniff consent to import my medication history as provided by SureScripts. ALLERGIES (food,latex,other)
NEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
Address: 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
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight: