PATIENT INFORMATION FORM

Transcription

1 PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor): Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Marital Status: Single Married Widowed Divorced Language: English Spanish Other Race: Caucasian or White Black or African American American Indian Alaska Native Asian Native Hawaiian Pacific Islander Other Ethnicity: Hispanic/Latino Not Hispanic/Latino EDUCATION Highest Level of Education: None Home-schooling Elementary High School GED Trade School Technical School College Post-College EMPLOYMENT Patient/Parent s Employer: Phone Number: Occupation: Been Exposed to Hazardous Materials (ex: asbestos, radiation, TB, etc.): Yes No Spouse s Last Name: First Name: Middle Initial: DOB: Spouse s Employer: Phone Number: INSURANCE Primary Insurance Company: Plan #: Policy Holder: Policy Holder DOB: Policy Holder SSN: Secondary Insurance Company: Plan #: Policy Holder: Policy Holder DOB: Policy Holder SSN: Primary Care Physician: Emergency Contact - Individuals with whom we may discuss medical care/authorization for treatment: Name/Relationship: _ Phone Number: Name/Relationship: _ Phone Number: Power of Attorney: Do you have an Advanced Directive? (End of Life Care) Yes No How did you hear about us? TV/Radio Newspaper Community Friend/Relative Social Media Mailer Other Signature of patient or guardian Date Patient Information Form Page 1

2 NEW PATIENT HISTORY FORM Patient Medical History/Conditions Reason for Visit: Primary Care Physician: Referring Physician: Please list where you have traveled recently: Any religious, cultural or spiritual beliefs that may affect your treatment? Yes No Preferred Local Pharmacy/Mail Order Pharmacy: Allergies: None Penicillin Sulfa Drugs IVP Dye Food: Past Medical History (Please check all that apply): Allergies COPD Liver Disease Anemia Coronary Artery Disease Migraine Headaches Angina Crohn s Disease Myocardial Infarction Anxiety Depression Osteoarthritis Arthritis Diabetes Osteoporosis Asthma Gallbladder Disease Peptic Ulcer Disease Arial Fibrillation GERD Renal Disease Benign Prostatic Hypertrophy Hepatitis C Seizure Disorder Blood Clots HIV Thyroid Disease Cancer (type) Hypertension Valve Disease CVA (stroke) Irritable Bowel Disease

3 Past Surgical History (Please check all that apply): Angioplasty Cholecystectomy (Gall Bladder) Lasik Angioplasty with Stent Colectomy Liver Biopsy Appendectomy Colostomy ORIF Arthroscopy Knee Ear Tubes Pacemaker Back Surgery Gastric Bypass Small Bowel Resection CABG (Heart Bypass Hernia Repair Thyroidectomy Carpal Tunnel Release Hip Replacement Tonsillectomy Cataract Extraction Knee Replacement Male Specific Prostate Biopsy TURP Vasectomy Female Specific Hysterectomy (ovaries removed) Preventative Care - Year of Last: Colonoscopy Flu Shot Mammogram Pap Smear Pneumonia Shot Prevnar 13 Shingles TDAP Social History: Religious Preference: Special Diet Restrictions: Typical Diet (ex: vegetarian, junk food, low fat, etc.): Frequency of Exercise: None/Occasionally 1-2 times/week 3-5 times/week Every day Type of Exercise (ex: aerobic, walking, martial arts, etc.): Drug Usage: Never Occasionally Regularly Used in the past Year Quit: Type of Drug(s) (ex: acid, cocaine, marijuana, etc.): Route of Drug(s) (ex:, inhale, in muscle, oral, etc.): Alcohol Usage: Never Occasionally Regularly Used in the past Year Quit: Alcohol Type: Drinks Per Week: Years Used: Tobacco Usage: Never Occasionally Regularly Used in the past Year Quit: Type: Packs/Cans Per Day: Years Used: Exposed to second hand smoke: Yes No

4 Social History Continued: Caffeine Usage: Yes No Amount Per Day: 1-2 Servings 2-4 Servings More than 4 Servings Type: Coffee Chocolate Sexually Active: Yes No Family History (Please check all that apply): ADD/ADHD Mother Father Brother Sister Other Alcoholism Mother Father Brother Sister Other Allergies Mother Father Brother Sister Other Alzheimer s Disease Mother Father Brother Sister Other Asthma Mother Father Brother Sister Other Blood Disease Mother Father Brother Sister Other Breast Cancer Mother Father Brother Sister Other Colon Cancer Mother Father Brother Sister Other CVA (stroke) Mother Father Brother Sister Other Depression Mother Father Brother Sister Other Developmental Delay Mother Father Brother Sister Other Diabetes Mother Father Brother Sister Other Eczema Mother Father Brother Sister Other Hearing Deficiency Mother Father Brother Sister Other Heart Disease Mother Father Brother Sister Other High Blood Pressure Mother Father Brother Sister Other Hyperlipidemia Mother Father Brother Sister Other Irritable Bowel Disease Mother Father Brother Sister Other Learning Disability Mother Father Brother Sister Other Mental Illness Mother Father Brother Sister Other Migraines Mother Father Brother Sister Other Obesity Mother Father Brother Sister Other Osteoarthritis Mother Father Brother Sister Other Prostate Cancer Mother Father Brother Sister Other PVD (Blood flow problems: arms, legs, neck) Mother Father Brother Sister Other Renal Disease Mother Father Brother Sister Other Seizure Disorder Mother Father Brother Sister Other Thyroid Disease Mother Father Brother Sister Other

5 Please list each family member (Parent/Sibling) that have had any of the following diseases/disorders: Bleed Disorder: Heart Disease: Palpitations: Diabetes Melitus: Stroke: Stents or Bypass: Heart Valve Problems: Liver Disease: Premature Coronary Heart Disease (Family Member < 55 years old with heart blockage or heart attack): Signature of patient or guardian Date

6 MEDICATION LIST FORM PHARMACY INFORMATION Pharmacy Name: Location: MEDICATIONS Name Dosage How often taken Medication List Form Page 6