NEW PATIENT REGISTRATION
Patient Legal Name
First Name
Last Name
Date of Birth
*
Sex
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone #
*
Social Security #
Email Address
*
Place of Birth
*
Education Level
Current Student?
Yes
No
If so, grade level?
Marital Status
*
Married
Single
Divorced
Other
Employed
Employed
Retired
Unemployed
Other
Employer
Employer Phone #
Occupation
Race
*
Please Select
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Preferred Language
Interpreter Needed
Sign
Speech
N/A
Do you have any mobility difficulties requiring assistance(ie: wheelchair)?
Yes
No
EMERGENCY CONTACT
Name
Relationship
Phone
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PRIMARY INSURANCE
Primary Insurance
Subscriber Name
Insurance ID #
Group #
Effective Date
DOB
Social Security #
Subscribers Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscribers Relationship to Patient
Employer
Picture of Prescription Card
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of
Picture of Primary Insurance Card
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of
Picture of Driver's License or Photo ID
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of
SECONDARY INSURANCE
Secondary Insurance
Subscriber Name
Insurance ID #
Group #
Effective Date
DOB
Social Security #
Subscribers Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscribers Relationship to Patient
Employer
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ALLERGIES (Medication/Food/Environmental)
Substance
Reactions
HEALTH MAINTENANCE
Date of last exam
Diabetic Eye Exam
-
Month
-
Day
Year
Date
Diabetic Foot Exam
-
Month
-
Day
Year
Date
Colonoscopy
-
Month
-
Day
Year
Date
Pap
-
Month
-
Day
Year
Date
Mammogram
-
Month
-
Day
Year
Date
PRESCRIPTION MEDICATION/SUPPLEMENTS
Name
Dose
Times per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
FAMILY HISTORY
Living
Age at Death
Current Age
Medical Problems
Father
Yes
No
Mother
Yes
No
Brother
Yes
No
Sister
Yes
No
Child#1
Yes
No
Child#2
Yes
No
Child#3
Yes
No
MEDICAL HISTORY
(Surgeries within the Year: Major Illnesses/Injuries; Etc…)
High Blood Pressure
High Blood Pressure
High Cholesterol
Diabetes
COPD/Lung Disease
Heart Disease
Kidney Disease
Cancer
If Cancer, type of cancer
Other
Current Smoker
Yes
No
If current, what type and how much?
Former Smoker/User
Yes
No
Are you interested in quitting?
Yes
No
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