PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:

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Transcription:

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 PHONE: ( ) EMPLOYER ADDRESS OCCUPATION: CITY: STATE: ZIP: EMERGENCY CONTACT PH# ( ) RELATIONSHIP: PRIMARY CARE PHYSICIAN: PERSON COMPLETING FORM (if different) REFERRING PHYSICIAN: RELATION TO PATIENT INSURANCE INFORMATION (MUST BE COMPLETED) PRIMARY INS CO. ID# Group# NAME OF POLICY HOLDER: DOB: SS#: SECONDARY INS CO. ID# Group# NAME OF POLICY HOLDER: DOB: SS#: RACE/ETHNICITY/PREFERRED LANGUAGE Race (choose one): American Indian Asian Black Native Hawaiian White Unknown Refuse to answer Ethnicity (choose one): Hispanic origin Non-Hispanic origin Unknown Refuse to answer Preferred Language: **I consent to allow Ear, Nose and Throat Associates of Southeastern Connecticut, P.C. to contact me and leave messages, including test results and appointment confirmations, in the following manner (check all that apply), please note written communication may require a fee: Text Appointment Reminders? Email Appointment Reminders? Telephone Appointment Reminders? Yes No Yes No Yes No Cell# email: Preferred#: May we leave test results and/or discuss your medical condition with family members? YES NO PERSONAL REPRESENTATIVE Please list the name(s) of anyone you designate as your personal representative to discuss protected health information if required. Name(s): SIGNATURE DATE

Name NOSE & ASSOCIATES OF SEC1 Past Medical, Social & Family History Height: Weight: Marital Status: El S El M El W El I Female only: Is there a chance you may be pregnant? 0 No 0 Yes Last menstrual period Do you have a living will? 0 No 0 Yes Name of Health Care representative (if applicable): PAST MEDICAL HISTORY/SYSTEM REVIEW Check off if you ever had any of these conditions : (unchecked box implies you NEVER have had the condition) El Asthma COPD/Emphysema 0 Heart Disease 0 High Blood Pressure El Strokes El Arthritis 0 Diabetes 0 Thyroid Disease 0 HIV/AI DS 0 Lupus 0 Seizures 0 GERD El Hiatal Hernia 0 Irritable Bowel Ei Hepatitis 0 Enlarged Prostate 0 Kidney Stones 0 Urinary Prob El Pancreatitis 0 Glaucoma El Cataracts El Depression/Anxiety le Psychosis El Sleep Apnea 0 Migraines 0 Peptic Ulcers 0 Other O Cancer (Type): El None of the above Past Hospitalizations/Surgeries and s: SOCIAL HISTORY El Alcohol - Type Amount per week O Cigarettes - Packs per day Years smoking O Coffee/Tea - Cups per day 1=1 Soda - Type/Amount per day Have you ever been treated for alcohol or substance abuse? 1=1 No LI Yes year q FAMILY HISTORY (Please describe your relationship to affected family members) O Heart Disease 0 Diabetes lilasthnna LI Stroke LlThyroid 0 High Blood Pressure O Bleeding Problems El Hearing Loss El Problems with Anesthesia 1=1 Cancer (Type) Patients Signature

Name NOSE & ASSOCIATES OF SEC1 REVIEW OF SYSTEMS (Do you currently have any of the following complaints-please check off): GENERAL (Constitutional/endocrine/heme) El chronic fatigue J weight loss El excessive urination El weight gain El fever El intolerance of hot/cold El easy bruising/bleeding LI swollen glands LI anemia S, EYES, NOSE, El ringing in the ear El ear infections Eli poor vision El sinus complaints El hearing loss LI blurring El sore throat El hoarseness LUNGS El short of breath El cough El pneumonia El asthma/bronchitis HT El chest pain El irregular heart beat El palpitations El blood clots SKIN (skin, allergy, immune) El rashes hay fever dry skin El hives GASTROINTESTINAL El heartburn El constipation El blood in stool El diarrhea El nausea/vomiting El liver disease URINARY El kidney stones El blood in urine El urinary infections El renal disease MUSCULOSKELETAL El arthritis El gout El chronic pain El muscle aches NEURO/PSYCH El stroke El numbness/tingling El panic El tremor El migraine El headaches El memory loss El depression/anxiety El seizures

Name: p:cerf- 0_0 19-46 NOSE & : Alys.oc ASSOCIATES OF SECT Pharmacy: MEDICATIONS AND ALLERGIES Town: PLEASE LIST YOUR CURRENT MEDICATIONS. Please include herbal supplements, vitamins and over-the-counter medications. Medication Dose Frequency Reason LERGIES: Do you have any MEDICATION allergies? LI No ['Yes IF YES, PLEASE LIST: Do you have an allergy to Latex? ON DYes

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