Demographics
Patient Name
*
First Name
Last Name
Patient’s sex
*
Male
Female
Other
Patient’s Date of Birth
*
-
Month
-
Day
Year
Date
Patient’s Social Security Number
Patient’s Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact number for patient
*
-
Area Code
Phone Number
May we leave information at this number?
*
Yes
No
What kind of information may we leave at this number?
*
Appointments
Provider Messages
Billing Information, including account balances
Medical Information
Other
How detailed may the message left at this number be?
*
Simple
Moderate
Detailed
Patient Work Number
-
Area Code
Phone Number
Patient’s Email
*
example@example.com
Employment Status of Patient
Full Time
Part Time
Not Working
Disabled
Retired
Student
Other
Name of Employer
Marital Status of Patient
Single
Married
Divorced
Widowed
Other
Language(s) spoken by patient
English
Spanish
Other
What category best describes your race (one or more may be marked)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
I choose not to answer
Other
Please specify your ethnicity
Hispanic or Latino
Not Hispanic or Latino
Nationality of Patient
U.S. citizen
Other
Emergency Contact Information
Emergency Contact for patient
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
May we leave information at this number?
*
Yes
No
What kind of information may we leave at this number?
*
Appointments
Provider Messages
Billing Information, including account balances
Medical Information
Other
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How is the emergency contact related to patient?
*
Other Contact Name
First Name
Last Name
Other Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Contact Phone Number
-
Area Code
Phone Number
How is other contact related to the patient?
Primary Insurance Information
Do you have health insurance?
*
Yes
No-I am self pay
Insurance Company Name (primary)
Subscriber’s Insurance ID number
Group Number
Primary Insurance Effective Date
-
Month
-
Day
Year
Date
Primary Insurance Subscriber’s Name
Primary Insurance Subscriber’s Date of Birth
-
Month
-
Day
Year
Date
Primary Insurance Subscriber’s Sex
Female
Male
Patient’s relationship to subscriber of Primary Insurance
Spouse
Child
Other
Secondary Insurance Information
Secondary Insurance Carrier
Secondary Insurance Subscriber ID number
Secondary Insurance Subscriber’s Name
Secondary Insurance Subscriber’s Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Subscriber’s Sex
Female
Male
Patient’s relationship to subscriber of Secondary Insurance
Spouse
Child
Other
Educational and Employment History
Please list any developmental delays and treatments for them that you underwent as a child (OT, PT, speech therapy, etc)
Please list any learning issues and treatments received as a child (include speech therapy, OT, IEP/540, etc)
Highest level of eduation
Non-HS graduate
GED
High School
2 year degree
4 year degree
Graduate degree
Post graduate
Vocational training
Employment
Full Time
Part time
Stay at home
Retired
Unemployed/not working
Furloughed
Short term disability
Long term disability
Student
Self employed
Other
Occupation
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