Patient Demographics Form

Patient Demographics

Please fill out for New and Exisitng patients to update your demographics in our systems.
Patient Name*

PrefixFirst NameMiddle NameLast NameSuffix
Patient’s sex*

MaleFemaleOther
Patient’s Date of Birth*

MonthDayYear
Date
Patient’s Social Security Number
Patient’s Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Cell Phone Number

Area CodePhone Number
Patient Home Phone Number

Area CodePhone Number
Patient Work Number

Area CodePhone Number
Patient’s Email
example@example.com
Marital Status of Patient

SingleMarriedDivorcedWidowedOther
Employment Status of Patient

Full TimePart TimeNot WorkingDisabledRetiredStudentOther
Name of Employer
Language(s) spoken by patient

EnglishSpanishOther
What category best describes your race (one or more may be marked)

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteI choose not to answerOther
Please specify your ethnicity

Hispanic or LatinoNot Hispanic or Latino
Nationality of Patient

U.S. citizenOther
Emergency Contact Information
Emergency Contact for patient

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How is the emergency contact related to patient?
Patient Medical History
Have you ever been treated any of the following medical conditions?

Acid Reflux (GERD)ArthritisAsthmaBleeding DisordersCancerChronic painCOPD/EmphysemaDementia or memory lossDiabetes mellitusHead trauma/loss of consciousnessHeart disease/heart attackHepatitis BHepatitis CHigh blood pressureHigh choleterolHigh thyroid functionHIV diseaseIron deficiency/anemiaIrritable Bowel SyndromeKidney diseaseLow thyroid functionMigraines or chronic headachesParkinson's diseasePituitary tumorSeizures/epilepsySleep apneaStroke or TIA (min-stroke)Vitamin B12 deficiencyVitamin D deficiencyNoneOther
Please list any other medical conditions not listed above
Primary Care Provider Name

First NameLast NameSuffix
Primary Care Provider Phone Number

Area CodePhone Number
Drug Allergies
Your other healthcare providers
I agree that the above informtion will be added to the systems of NuRx Pharmacy LLC to update and add demographic information for the above patient. By Signing below you authorize NuRx Pharmacy to update and store all of your information.
Signature
Should be Empty:

Patient Demographics

Emergency Contact Information

Patient Medical History