Registration Date MM slash DD slash YYYY Home PhonePatient First NamePatient Last NameResponsible Party (if a minor):Street Address City State / Province / Region ZIP / Postal Code Sex Male Female AgeBirthdate MM slash DD slash YYYY Marital Status Single Marriage Widowed Separated Divorced Which of the following best describes your current status? Employed Full-Time Student Part-Time Student Patient’s School Name:Patient Employed By:Business Address:Occupation:Business PhoneSpouse (or responsible party) Name:Birthdate: MM slash DD slash YYYY Business Name and Address:Occupation:Business PhoneWho is responsible for this account?Relationship to Patient:Social Security #:Spouse’s Social Security #:Do you have Medical Insurance? Yes No Name of Primary Insurer:Contract #:Group #:Subscriber #:Name of Secondary Insurer (if any):Contract #:Group #:Subscriber #:Are you covered under any of these programs? Medicare Medicaid CHAMPUS CHAMPVA Worker Compensation FECA Black Lung I.D. # for program you’ve checked:If Welfare, Your number:County of:Is your condition related to employment (current or previous)? Yes No Is your condition related to auto accident? Yes No In which state?Other Accident? Yes No Please DescribeIn case of emergency, who should be notified?PhoneRelationship to patientPlease list other doctors you have seen in the past 5 years:City/StateReason for seeingCity/StateReason for seeingHow did you learn of our practice?Whom may we thank for referring you?ASSIGNMENT AND RELEASEI, the undersigned, have insurance coverage withand assign directly to all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.Signature Of Insured/GuardianDate MM slash DD slash YYYY MEDICARE AUTHORIZATION I request that payment of authorized Medicare benefits be made either to me or on my behalf to for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.Beneficiary SignatureDate MM slash DD slash YYYY Office Notes Add RemovePatient History FormNameAgeBirthdate MM slash DD slash YYYY AddressBirthplaceCityStateZipReligionAlternate AddressMarital StatusAddressOccupationCityStateZipList all States and Countries in which you have lived:PhoneAlternative PhoneHave LivedEducation (brief description)HPI : (to be filled in by the physician)Past Medical History: List all illnesses for which you have been treated in the past. (Include those requiring hospitalization.) Add RemovePast Surgical History: List all surgeries (include dates and place of operation) Add RemoveFamily HistoryRelationAgeLiving Yes No FatherMotherB / SB / SB / SB / SSpouse Children Add RemoveHas any blood relative ever had: Yes No Relation Cancer Yes No Diabetes Yes No Heart Disease Yes No Stroke Yes No High Blood Pressure Yes No Thyroid Problems Yes No Epilepsy Yes No Tuberculosis Yes No Mental Illness Yes No Kidney Problems Yes No Suicide Yes No Habits: Do you… Sleep well? Yes No Use alcoholic beverages? Yes No How much?Use Tobacco? Yes No How much?How long?Exercise? (describe)WOMEN ONLY:Menstruation history:Age of onset? Yes No Cycles: (circle one) REGULAR OR IRREGULARDuration:Flow: (circle one) HEAVY / MEDIUM / LIGHTPain or Cramps? Yes No Contraceptives? Yes No Last Menstrual Period:Number of Pregnancies:Full Term:Premature:Abortions:Miscarriages:Living:Complications:List ALL medications with dosage schedules: Add RemoveMEDICATION ALLERGIES: Add Remove(Circle any symptoms you may have now. If any were present in the past, explain on the next page. Fill in answers when appropriate.)WeightWeight at age 18Recent change of weight?how much?AppetiteWeaknessfatiguefeverchillsnight sweatsanorexiasyncopeinsomniasleeping habitsSkin color change itching rash moles change in moles infections cancer Head Headaches trauma Eyes vision glasses blindness or blind spots pain tearing redness itching burning dryness glaucoma Ears hearing loss deafness discharge pain vertigo tinnitus Nose and sinuses decreased sense of smell bleeding dryness discharge obstruction pain sinusitis hay fever Mouth cavities painful teeth bleeding gums sore tongue postnasal drip oral ulcers thrush lip lesion fever blisters canker sores Throat Sore throat hoarseness painful swallowing tonsillitis Breasts lumps discharge pain bleeding nipple inversion change in size tenderness Respiratory cough sputum color? pleurisy coughing up blood wheezing shortness of breath recurrent respiratory infection exposure to tuberculosis positive TB skin test Cardiac chest pain shortness of breath on exertion palpitations swelling ever pass out? rheumatic fever abnormal EKG? if so, when? Vascular high blood pressure phlebitis varicose veins blood clots leg cramps with walking Raynaud’s phenomenon GI nausea vomiting vomiting up blood heartburn problems swallowing jaundice clay-colored stools dark urine recent change in bowel habits blood in stools black tarry stools hemorrhoids rectal abscess or fissure hernia GU painful urination poor urinary stream frequent awakenings to urinate incontinence kidney stones frequent urine infections (cystitis, prostatitis) venereal disease vaginal/pelvic infections impotence MS muscle pain cramps weakness joint pain stiffness or deformity broken bones Endocrine heat or cold intolerance frequent drinking frequent urination goiter CNS seizures strokes tremor incoordination fainting numbness tingling memory loss depression anxiety nervous breakdown
