plattevalleyinternalmedicine-New Patient Form

New Patient Form
Name

First NameMiddle NameLast Name
Patient Birth Date

MonthDayYear
Date
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient SSN
Patients Email
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
RACE:

American IndianAsianBlack/African AmericanHispanicWhite/CaucasianDeclinedOther
LANGUAGE:

EnglishSpanishDeclinedOther
MARITAL STATUS:

SingleMarriedDivorced/separatedWidow/WidowerDeclinedOther
Patients Preferred Pharmacy
Pharmacy Address
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Patients Employer
Employer Address
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Primary Insurance:
Policy Number:
Group Number:
Insured (Guarantor) Name:
DOB:

MonthDayYear
Date
Last Four SSN: XXX-XX-
Relationship to Patient:
Secondary Insurance:
Policy Number:
Group Number:
Insured (Guarantor) Name:
DOB:

MonthDayYear
Date
Last Four SSN: XXX-XX-
Relationship to Patient:
Is this appointment related to an accident?

YesNo
Are you retired from Rocky Flats?

YesNo
Assignment and release: I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non- covered and/or not medically necessary services as determined by my insurance. I also authorize the physician to release any information required in the processing of this claim and future claims. I also hereby acknowledge that I hereby received or have been offered a copy of the practices Notice of Privacy Practice.
Patient or Legal Guardian Signature:
Date

MonthDayYear
Date
Patient Name:
PCP:
Current taking any Medications

YesNo

Rows	Medication	Dosage

Medication Allergies and Reaction:
Date of Your Last:

MonthDayYear
Date

Type a question

Rows	Date
AAA Screening
Bone Density (DEXA Scan)
Cervical Cancer Screening (Pap Smear)
Hepatitis C Screening
PSA (blood test)
Prostate Exam
Hearing Exam
Vision Exam

Colon Cancer Screening type

ColonoscopyCologuardFIT TestFOBTSigmoidoscopy

Vaccinations:

Rows	Date
Flu Shot
Hepatitis A
Hepatitis B
HPV
Meningitis
Pneumovax
Prevnar 13
Shingles
Tetanus Shot
Tetanus with Pertussis
Covid -19

Pediatric Vaccines: Please provide a copy of your child's immunization record.
Health History
Have you ever had any of the following:

AIDSAnemiaAsthmaAtrial FibrillationBleeding DisorderBlood ClotBone LossCataractsChest PainChronic FatigueCOPD/EmphysemaDepressionDifficulty HearingDiverticulitiesDizzy SpellsFibromyalgiaFrequent Ear InfectionFrequent Urinary InfectionGERD(Heartburn)GI BleedGlaucomaHeadachesHead Injury/ConcussionHearing FailureHeart Arrhythmia/PalpitationsHemorrhoibsHIVHigh Blood PressureKidney DiseaseMemory LossPeripheral Artery DiseasePneumoniaSeizuresShortness of BreathSinusitis, recurrentSleep IssuesStrokeTB/Lung DisorderThyroid DisorderUlcers
Ever Had Arthritis

YesNo
Type
Ever Had Cancer

YesNo
Type
Ever Had Diabetes

YesNo
Type
Ever Had Hepatitis

YesNo
Type
Ever Had MI( Heart Attack)

YesNo
Date

MonthDayYear
Date
Additional medical conditions your doctor should know about:
Surgical HistoryHeading

Type a question

Rows	Surgery/Procedure	Year	Hospital/Location	Complications/Comments

Hospitalizations in The Past Year:Type a question
Where do you go for bloodwork?

QuestLabcorpHospitalOther
Do you have a Living Will?

YesNo
Do you have a DNR?

YesNo
Do you have a Medical Durable Power of Attorney?

YesNo
If Yes, Print Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social History
Tobacco— Smoking

NeverFormerCurrentPassive Smoke ExposureCigarettesPipeCigar
Start Date

MonthDayYear
Date
Quit Date

MonthDayYear
Date
#years:
#Packs/Day:
Tobacco— Smokeless

NeverFormerCurrent
Type

SnuffChew
E-Cigarettes

NeverFormerCurrent
#Cartridges/Day:
Start Date

MonthDayYear
Date
Quit Date

MonthDayYear
Date
Alcohol

NeverFormerMonthly or Less2-4 times/month2-3 times/week4 Or more times/week
Substance Abuse

NeverFormerCurrent
Type:
How Often:
Sexually Active

NeverYesNot CurrentlyMale PartnersFemale Partners
Type of Birth Control/Protection:
Diet (Check all that apply)

Well BalancedDiabeticExcessive Fat/CaloriesVegetarianWeight Loss ProductsVitamins/HerbalsRoutine MealtimesCaffeineOther
Exercise

YesNo
#days/week on average you engage in moderate to strenuous exercise?
#minutes you exercise per day on average:
Safety (Check all that apply)

CO detector in homeGuns Unloaded/LockedHelmet UseSeat Belt UseSmoke detector in homeSunscreen UseWater Heater Temp SetCaffeine
With Whom Do You Live

AloneChildrenParent(s)Spouse/PartnerExtended FamilyOther
Family History

Rows	Father	Mother	Brother	Sister	Son	Daughter	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
No Known
Problems
Alcohol Abuse
Asthma
Bleeding Disorder
Breast Cancer
Colon Cancer
Ovarian Cancer
Prostate Cancer
Other Cancer(s)
Dementia
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Lung Disease
Mental Illness
Stroke
Thyroid Disease

Rows	Alive	Deceased	At What Age:
Father
Mother
Brother
Sister
Son
Daughter
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Are you adopted?

YesNo
Additional family history your doctor should know about:
Should be Empty:

New Patient Form

Insurance Information

Health History

Surgical HistoryHeading

Social History

Family History