Patient Registration Form
PATIENT INFORMATION (Please Print)
Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Other
Patient’s Name (Last) (First) (MI) Previous Name
Mailing Address
City, State, ZIP (+4)
Physical Address
City, State, ZIP (+4)
Phone Numbers W o r k Day Evening Home Day Evening
Cellular Pager
Primary Care Provider (PCP) Referring Physician
Date of Birth (MM/DD/YYYY) Sex Male Female Transgender
Marital Status Married Single Divorced Widowed Legally Separated Partner
Social Security Number - - E-mail Address
Employment Status 1- Full-Time 2- Part-Time 3-Not Employed 4- Self-Employed 5-Retired 6-Active Military Student Status 1- Full-Time Student 2- Part-Time Student N- Not a Student
Race Ethnicity Language
EMERGENCY CONTACT INFORMATION (information used for emergencies only)
Emergency Contact Name Phone Number
Emergency Contact Relationship to Patient Guardian
Address City; State; Zip (+4):
RESPONSIBLE PARTY INFORMATION (information used for patient balance statements)
Responsible Party Another Patient Guarantor Self Check here if information is same as patient
Responsible Party Name (Last) (First) (MI)
Guarantor Account # Date of Birth (MM/DD/YYYY) Male Female
Social Security Number - - Phone #(s)
E-Mail Address
Mailing Address Physical Address
City, State, ZIP (+4) City, State, ZIP (+4)
Employer Employer Phone Number
Patient Relationship to Responsible Party
PRIMARY INSURANCE INFORMATION (provide your insurance card(s) to the front desk at check-in)
Insurance Company/Phone Number ( )
Name of Insured Patient Relationship to Insured
Subscriber ID (Policy Number) Group ID Copay Amount
Effective Date Termination Date ______________
Insured Date of Birth / / Insured’s Social Security Number - _____________
SECONDARY INSURANCE INFORMATION (provide your insurance card(s) to the front desk at check-in)
Insurance Company/Phone Number
( )
Name of Insured Patient Relationship to Insured
Subscriber ID (Policy Number) Group ID Copay Amount
Effective Date Termination Date ____________
Insured Date of Birth / / Insured’s Social Security Number _____
PRIMARY PHARMACY INFORMATION (provide your primary pharmacy to the front desk at check-in)
Pharmacy Name/Phone Number ( )
Address City; State; Zip (+4)
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient (or Responsible Party) Signature Date
PATIENT HISTORY FORM
NOTE: This is a confidential record and will be kept in your doctor’s office.
Information contained here will not be released to anyone without your authorization to do so.
Date:
Full Name: Date of Birth: Age:
Referred by: Primary Care Physician:
Chief Complaint (reason for your visit today):
How long have you had this problem?
Previous Surgeries: When?
List ALL medications you are taking at the present time:
Do you have any problems with anesthesia? No Yes Do you take any of the following?
Aspirin No Yes How much/how often?
Coumadin (warfarin) No Yes How much/how often?
Plavix (clopidogrel) No Yes How much/how often?
Lovenox (enoxaparin) No Yes How much/how often?
Other blood thinners:
Allergies to medications:
ARE YOU ALLERGIC TO X-RAY DYE? No Yes Social History
Marital Status: Single Married Separated Divorced Widow(er)
Most Recent Occupation: _
Use of Alcohol: Never Rarely Moderate Daily
FAMILY HISTORY No Yes
Alcoholism Arthritis/Gout Bleeding Disorders Cancer
Diabetes Heart Disease Hepatitis
High Blood Pressure Kidney Trouble/Stones Mental Illness Seizures Stroke Tuberculosis Other
Current No Yes If yes, what type and how often?
Past No Yes If yes, what type and how often?
PAST MEDICAL HISTORY
(problems you have now) No Yes AIDS
Alcoholism Anemia Arthritis/Gout Bleeding Disorders Blood Clot Cancer Diabetes Heart Disease Hepatitis
High Blood Pressure Kidney Trouble/Stones Liver Trouble Lung Disease Mental Illness Phlebitis Seizures Stomach ulcers Stroke Thyroid Trouble Tuberculosis Other Illnesses
Use of Tobacco:
Do you currently smoke? No Yes If yes, how long/how much?
Do you use smokeless tobacco?
Use of Illicit (Illegal) Drugs:
No Yes If yes, how long/how much?
REVIEW OF SYSTEMS
Do you now have or have had any problems related to the following systems? Check Yes or No.
Please explain any that you answer “Yes” in the space provided.
Constitutional Symptoms
Fever YES NO Eyes
Blurred vision YES NO
Chills YES NO Double vision YES NO
Headache YES NO Pain YES NO
Other Other
Allergic/Immunologic Musculoskeletal
Hay fever YES NO Joint pain YES NO
Drug Allergies YES NO Neck pain YES NO
Other Back pain YES NO
Other Neurological
Tremors YES NO Ears/Nose/Throat/Mouth
Ear infections YES NO
Dizzy spells YES NO Sore throats YES NO
Numbness and tingling YES NO Sinus problems YES NO
Other Other
Endocrine
Too hot/cold YES NO Respiratory
Wheezing YES NO
Excessive thirst YES NO Frequent cough YES NO
Tired/sluggish YES NO Shortness of breath YES NO
Other Other
Gastrointestinal Psychological
Nausea/vomiting YES NO Memory loss and confusion YES NO
Indigestion/heartburn YES NO Nervousness YES NO
Hiatal hernia YES NO Depression YES NO
Other Other
Hematologic/Lymphatic Integumentary
Swollen glands YES NO Skin rash YES NO
Blood clotting problems YES Are you taking blood thinners
NO Boils
Persistent itch
YES
YES NO
NO
At the present time? YES NO Other
Cardiovascular
Chest pain YES NO
Varicose veins High blood pressure
YES
YES NO
NO Other
UNIVERSAL MEDICATION LIST (UML)
Name: Address:
Phone Number:
Birthdate:
Allergic To/Describe Reaction: Allergic To/Describe Reaction
List all prescription and over-the-counter (non-prescription) medications such as vitamins, aspirin, Tylenol, and herbals (ex: Ginseng, Gingko Biloba, and St. John’s Wort). Include prescription medications taken as needed (ex. Viagra, nitroglycerin)
NAME OF MEDICATION Dose How Often? Date and time last taken
(AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION PHI)
Patient Name: Birth Date: SSN:
Address: MR#:
I authorize:
(Name and Address of Person or Facility which has Health Information) To Use and/or disclose the following Protected Health Information (PHI) to:
(Name and Address of Person or Facility to receive Health Information)
This PHI is being Used and/or Disclosed for the following Purpose:
For the Treatment Dates of:
Type of Access Requested: Copies of the Record Inspection of the Record Physician PCI Access Specific Information to be Used/Disclosed:
Discharge Summary
History & Physical Exam
Operative Reports
Pathology Reports
Consultations
Emergency Room Record
Laboratory Reports
Radiology/Imaging Reports
Progress Notes
Physician Orders
Cardiac Cath Reports
Cardiac Studies
Demographic Record
Patient Care Notes
Medication Record
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information . (Initial)
I understand:
1. This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for 1) conducting research-related treatment. 2) To obtain information in connection with eligibility for enrollment in a health plan. 3) To determine an entity’s obligation to pay a claim, or 4) to create health information to provide to a third party.
2. The person who receives the records to which this authorization pertains may not re-disclose them to anyone else without my specific written consent, except that such person may make a disclosure if it is permitted by federal or state law.
3. I am entitled to receive a copy of this authorization.
I have read the above and authorize the disclosure of the protected health information as stated.
Unless otherwise revoked, this authorization expires (insert applicable date or event). If no date is indicated, this authorization will expire 90 days after the date of signing this form.
Signature of Patient or Patient’s Legal Representative Date
Print Name of Patient’s Representative Relationship to Patient
Witness Date
