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Transcription:

First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native Ethnicity: Hispanic or Latino Married Asian Not Hispanic or Latino Partner Native Hawaiian Divorced Black or African American Language: English Separated White Spanish Widowed Hispanic Other Other Pacific Islander Other Race Preferred Pharmacy: City: Previous Physician(s): I do not have insurance. I have insurance. Responsible Party: Insurance Authorization and Assignment: Insurance Company Group ID Number Relationship: DOB: I authorize Blair Family Medicine, P.A. to release to my insurance company and/or their agents any information necessary to determine benefits payable or related services. I authorize the payment of medical benefits to Blair Family Medicine, P.A. I understand that I am ultimately responsible for all services whether covered by insurance or not. I also authorize my physician, based on his/her discretion, to access my chart for utilization management review. Signature Date

Main reason for today's visit: List all current medications, including any over-the-counter medications or supplements. I do not take any medications. Name of Medication Dosage Times per Day Last tetanus shot: Last flu shot: Last pneumonia shot: Date Date Date List any drug or food allergies or medicines you cannot take. I have no known drug allergies. I am allergic to latex. ROS, PMHx, RHx, SHx completed by patient and reviewed by physician

Have you ever had any problems with anesthesia? No Yes (being put to sleep for surgery) Have you ever had a serious injury? No Yes Please describe Please describe List any of your BLOOD RELATIVES who have a history of any of the following, and provide their relationship to you: Family history unknown Type Paternal or Maternal & Relationship Problems/Complications with Anesthesia Heart Problems: Hypertension Lungs Heart Attack Stroke Bleeding/Clotting Problems Diabetes Cancer Seizures Other Major Health Problems Current Occupation: Disabled Retired Student Religion: Tobacco Use: Never Cigarette Cigar Pipe Chew Age when started? Average use per day? Age when stopped? Alcohol Use: No Yes Types and average number per week? Beer: Wine: Wine Coolers: Mixed/Liquor: Have you ever been dependent on or addicted to any drugs? No Yes (please discuss with physician) ROS, FMHx, FHx, SHx completed by patient and reviewed by physician

Childhood Diseases Cancer Year Congenital (Birth) Problems Chicken Pox Breast Congenital Malformation Measles Colon Down Syndrome Mumps Lung Prematurity Prostate Skin Ears, Nose, & Throat Lungs Ear Infections Asthma (when diagnosed?) Hearing Loss Heart COPD Sinus Infections Angina (chest pain) Cystic Fibrosis Sleep Apnea Heart Attack Tuberculosis TMJ Dysfunction Hypertension Murmur Mitral Valve Prolapse Skin Digestive High Cholesterol Rosacea Diverticulitis High Triglycerides Acne Hemorrhoids Eczema Hepatitis - Type: A B C Bones/Joints Psoriasis Irritable Bowel Syndrome Arthritis Reflux Joints afected? Gallbladder Disease (stones) Glands/Hormones Osteo Rheumatoid Diabetes Osteoporosis Type I Type II Brain/Nervous System Insulin Requiring? Alzheimer's/Dementia Grave's Disease Seizures Mental/Emotional Health Thyroid Disease Multiple Sclerosis Anxiety Disorder Hyper Hypo Stroke Bipolar Disorder (type 1 or 2) Please specify when diagnosed. Headache Depression Migraine Suicide Attempted Allergies/Immune System History of any other condition AIDS/HIV Autoimmune Disorder Lupus Indicate any major surgeries you have had. Eyes Cataract LASIK Other Ears Ear Tubes Other Nose Rhinoplasty Septoplasty Sinus Other Mouth/Neck Tonsil/Adenoid Thyroid Other Heart Bypass Pacemaker Transplant Other Lungs/Chest Esophagus Lungs Other Digestive Hernia Gallbladder Appendectomy Other Female/Male Prostatectomy C-Section Hysterectomy Other Health Tubal Ligation Bladder Kidney Other Other (please describe) ROS, FMHx, FHx, SHx completed by patient and reviewed by physician

Please list the names of any other providers you see regularly or have seen within the past year. Specialty Name City Phone Fax OB/Gyn Cardiology Neurology Orthopedic Gastroenterology Urology Dermatology

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