TriState Family Practice & Internal Medicine New Patient Form

Family Practice & Internal Medicine New Patient Form

Please fill out your form as completely and accurately as possible. Information collected on this form will only be used by TriState Health to register for your appointment unless stated otherwise and approved with your clear written consent.
Which clinic would you prefer to be seen in?
Do you have a preference for which provider you hope to see?
Do you have a preference for which provider you hope to see?
Do you have a preference for which provider you hope to see?
Do you have a preference for which provider you hope to see?
Do you have a preference for which provider you hope to see?
Do you have a preference for which provider you hope to see?
Patient Information
Patient Name

First NameLast Name
Patient First Name
Patient Middle Initial
Patient Last Name
Previous/Maiden Name
Maiden Name
Social Security Number
Date of Birth

MonthDayYear
Date
Sex
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Type
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language
Race
If other, what is your race?
Email
example@example.com
Do you have a Guarantor?
Guarantor

First NameLast Name
Guarantor Relationship to Patient
Guarantor Date of Birth

MonthDayYear
Date
Emergency Contact Information
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Phone Type
Emergency Contact's Relationship to Patient
Emergency Contact's Relationship to Patient
Insurance Information
PRIMARY INSURANCE INFORMATION
Primary Insurance
Primary Insurance
Primary Subscriber Name
Primary Subscriber's Relationship to Patient (If you are the primary subscriber, please write "self.")
Primary Subscriber's Date of Birth

MonthDayYear
Date
Primary Insurance ID # (include alpha prefix, if applicable)
Primary Group #
Do you have secondary insurance?
SECONDARY INSURANCE INFORMATION
Secondary Insurance
Secondary Insurance Hide
Secondary Subscriber Name
Secondary Subscriber's Relationship to Patient (If you are the secondary subscriber, please write "self.")
Secondary Insurance ID #
Secondary Group #
Patient Employer Information
Employer Name
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer City
Employer State
Reason for Visit
What is the reason for your visit?
If other, please explain:
Previous Primary Care Provider (If none, type N/A):
Does the visit pertain to an injury or accident that we will bill to Worker's Compensation or other insurance?
Please choose which kind of injury or accident that this visit pertains to?
Auto Accident:
On the Job Injury:
Other Accident:
Allergies
Do you have any allergies or intolerance to medications or the environment (i.e. dust, nuts, animals)?
Please list any allergy or intolerance you have to medications or environment (i.e. dust, nuts, animals):
Current Medications
Are you currently taking any prescription or over-the-counter medications?
Please list all current medications- Include all prescription and non-prescription (over-the-counter) medications:
Past Medical History

(Women Only)
Age when menses began?
Are you post-menopausal?
When was your last period?
At what age did you have your first child? (Type N/A if this does not apply to you)
Total number of pregnancies?
Total number of miscarriages?
Health Conditions/Concerns
Please list your health conditions/concerns:
Past Surgeries/Procedures
Have you had any surgeries or procedures in the past?
Please list all past surgeries and/or procedures that you have had and when:
Vaccines/Immunizations
Where were your previous vaccines or immunizations completed?
Family History

Please check all that apply or choose None/Not Applicable

Choose which relative

Rows	Cancer	Dementia	Diabetes	High Blood Pressure	None/Not Applicable (N/A)
Mother
Father
Brother
Sister
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Social History
Please choose your marital status:
Do you currently or have you ever used tobacco products?
Please choose your tobacco smoking status:
Type of tobacco products used:
Smoking Start Date (enter date)Smoking End Date(enter date)
Do you currently or have you ever used alcohol?
Alcohol intake frequency:
In regards to recreational drugs, please select if you do not use, are a former substance user, or are a current user?
Type of recreational drugs used:
If other, please list:
Pharmacy Preference
What is your pharmacy of choice?
Location (City, State)
Additional Information
Please leave any additional comments or information that you would like to share here:
Communication

Please read statement regarding TriState communications and choose one option.
I hereby authorize TriState Health to contact me via my provided email for TriState related marketing communications. Treatment is not conditioned upon my authorization to agree to receive marketing communication and my authorization shall remain effective until canceled by me in writing to TriState Health.
Market Research Questions

**OPTIONAL: Please answer one question below about how you heard about TriState Health.
How did you hear about us? Please choose all that apply:
Please list below what other way you heard about us:
Should be Empty:

Family Practice & Internal Medicine New Patient Form

Patient Information

Emergency Contact Information

Insurance Information

Patient Employer Information

Reason for Visit

Allergies

Current Medications

Past Medical History

Health Conditions/Concerns

Past Surgeries/Procedures

Vaccines/Immunizations

Family History

Social History

Pharmacy Preference

Additional Information

Communication

Market Research Questions