New Patients Medical Registration
THIS REGISTRATION FORM IS ONLY FOR GONZAGA FAMILY HEALTH PRIMARY CARE. All patients are required to fill out a Medical registration form. This should take approximately 15-20 minutes to complete.
Patient Name
*
First Name
Middle Name
Last Name
Suffix
Patient Preferred Name:
Preferred First Name
Patient Sex
*
Male
Female
Transgender
Patient Date of Birth
*
/
Month
/
Day
Year
Date of Birth
Patient Social Security Number :(no dashes) PLEASE GIVE FULL 9 DIGIT NUMBER
*
(no dashes)
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Number
*
Preferred Phone Number
Format: (000) 000-0000.
Best Contact Number "Type": Please identify the Phone Number provided.
Cell Phone Number
Home Phone Number
Work Phone Number
Other Number
Best e-mail to reach you
*
example@example.com
Do you consent to receiving messages from GFH at the email address listed above?
*
Yes
No
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Some more personal information we need
Your Employment Status
*
Employed part time
Unemployed
Self-employed
Employed full time
Other
If you are employed, please provide your work phone number
-
Area Code
Phone Number
Are you of Hispanic/Latino decent?
*
Yes
No
Race:
Who is your current Primary Care Provider? (If you don't have a PCP, just put "N/A")
Marital Status
*
Married
Divorced
Widowed
Domestic Partnership
Single
Other
Name of your spouse or significant other. (If you are single, you can skip this question. )
First Name
Last Name
Phone number of your spouse or significant other.
-
Area Code
Phone Number
Emergency Contact:
*
First Name
Last Name
Phone Number of Emergency Contact:
*
-
Area Code
Phone Number
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Insurance Information
** PLEASE PROVIDE US WITH COMPLETE INSURANCE INFORMATION. IF WE DO NOT OBTAIN ALL INSURANCE INFORMATION WE WILL BE UNABLE TO SCHEDULE YOU FOR AN APPOINTMENT AT OUR PRACTICE. **
Will you be using insurance, or will you be paying out-of-pocket?
*
Insurance
Out of Pocket
Primary Insurance Name: (If out-of-pocket, please indicate by stating "N/A.")
*
Insurance Company Name
Primary Insurance Member ID: (If you have Insurance, PLEASE PROVIDE the ID Number!!)
*
Member or Subscriber ID Number
Group ID: (if applicable)
Group ID Number
Address where Insurance claims are to be sent. (Located on the back of the card.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of "Policy Holder":
First Name
Last Name
"Policy Holder's" Date of Birth:
-
Month
-
Day
Year
Date
Secondary Insurance Name: (if none, leave and all the rest blank)
Secondary Insurance Company Name
Secondary Insurance Member ID:
Secondary Insurance Member or Subscriber ID Number
Group ID: (if applicable)
Secondary Insurance Group ID Number
Address for Secondary Ins. where insurance claims are to be sent (located on the back of the card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of "Policy Holder" for Secondary Insurance: (ONLY if different from Primary Ins.)
First Name
Last Name
Date of Birth for Secondary Insurance "Policy Holder": (ONLY if different from Primary Ins.)
-
Month
-
Day
Year
Date
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Pharmacy and Medications
Please select the best option...
*
I have a pharmacy that I use.
I don't have a pharmacy.
I might be changing my pharmacy.
Pharmacy Name
Pharmacy Name
Pharmacy Location and Phone Number
Pharmacy Address and Phone Number
Preferred Lab Facility:
*
(Ex: Out Patient Diagnostic Center / Lab Corp)
Lab Facility Location:
Lab Address
Preferred Imaging Facility
*
(Ex: Outpatient Diagnostic Center / ADR)
Imaging Facility Location
Imaging Address
If you are prescribed any Medications, please list them here along with the dosage. This also includes any over the counter Supplements and Vitamins. If you are not taking any medication, type "N/A".)
*
Do you have any Allergies to any medications? If yes, list the medication name, type of reaction and severity of the reaction you have. If you do not have any know Allergies, type "N/A."
*
Last Influenza (Flu) Vaccine?
-
Month
-
Day
Year
Date
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Social and Surgical History
Are you able to care for yourself?
*
Yes
No
Do you have an Advance Directive?
*
Yes
No
Do you Exercise?
Yes
No
Do you drink Alcohol?
*
Yes
No
Historically, but not currently
If "YES" how many drinks do you consume in a week?
glass of wine / beer or mixed drinks per week
Do you have a history of Substance Abuse?
*
Yes
No
Historically, but not currently
If "YES" please write what Substances you have abused:
type of substances abused
Do you smoke?
*
Yes
No
If "YES" how many cigarettes do you smoke per day?
per day
Do you use : E-cigarette/Vape?
Yes
No
If "YES" How much, how often, and what type?
per day
Do you use chewing tobacco / smoke-less tobacco?
*
Yes
No
If "YES" How often do you use and how much per day?
per day
Are you sexually active?
Yes
No
Have you had the HPV vaccine?
Yes
No
Not Sure
Do you have an STI or a sexually transmitted disease?
Yes
No
Not Sure
Do you have any sexual problems you would like to discuss with the Provider?
Yes
No
Please list all past surgeries, the hospital or location they were performed and the approximate date. If you do not have any past surgeries to report, please type "N/A."
*
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Medical History
These condition are concerning the patient ONLY! Please put family medical history in its respected area!
CONDITIONS
ADD/ADHD
AIDS/HIV
Abuse/domestic violence
Allergies/hay fever
Anemia
Anesthesia Complications
Anxiety Disorder
Arthritis
Asthma
Autism spectrum disorder
CONDITIONS Continued...
Birth defects or inherited disease
Bladder or kidney problems
Blood diseases
History of blood transfusion
Breast cancer
Breast problem
COPD
Other type of cancer
Chicken Pox
CONDITIONS Continued...
Chronic ear infections
Congestive heart failure
Constipation outside of typical
Coronary artery disease
Depression
Developmental or behavioral disorders
Diabetes
Difficulty swallowing
Diverticulitis
CONDITIONS Continued...
Ear or hearing problems
Eating disorders
Eczema
Endometriosis
Fibromyalgia
GI problems (stomach)
Gout
Head injury or concussion
Frequent headaches
Heart problems
CONDITIONS Continued...YOU'RE ALMOST DONE!
Hepatitis
High cholesterol
Hypertension
Hyperthyroidism
Hypothyroidism
Infertility
Kidney disease
Kidney stones
Liver disease
Lung disease
Mental disorder
Muscle, joint, or bone problems
CONDITIONS Continued...The last batch.
Obesity
Osteoporosis
Ovarian cancer
Polyps
Pulmonary embolism
Reflux/GERD
Seizures or epilepsy
Skin problems
Stroke
Thyroid Problems
Turberculosis
Varicosites
Vision or eye problems
Please list any medical history or conditions of immediate blood relatives of the patient (Mother, Father, Material & Paternal Grandparents, Brother, Sister.)
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One Last Thing
We are always trying to improve the patient experience. If you could please take a minute and complete this small survey of your experience.
Overall, how was your experience filling out this form compared to other online forms?
*
1
2
3
4
5
6
7
Worst
Best
1 is Worst, 7 is Best
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