Patient Pre-Registration Application FORM

Patient Full Name*
First Name, Middle Initial, Last Name

Primary Physician*

Today's Date*

Street Address*
Full Street Address or P.O Box

City*

County*

State*

Zip Code*

Telephone*
Area Code and 7 Digit Number

Email Address*

Date of Birth*

Marital Status*
SingleMarriedDivorced

Sex*
MaleFemale

Race*
BlackWhiteAsianIndian

Last 4 Digits of Social Security Number*

Religion

Are you Employed?*
YesNo

Employer's Name
If you are employed please list your major employer's business name.

Employer's Street Address

City

State

Zip Code
Five Digit Zip Code

Employer Phone Number
Area Code Plus 7 Digit Number

Type of Position
Full TimePart Time

Occupation

Retirement Date
Fill In This Field Only If You Expect To Retire

When Paying Healthcare Bills...How Do You Plan To Pay?*
InsuranceCashMedicaidMedicare

Responsible Party's Information
Fill Out Below If The Patient Is Not The Responsible Party

Person Responsible For Bill

Date of Birth

Street Address or P.O. Box

City

State

Zip Code
Five Digit Zip Code

Telephone
Area Code and 7 Digit Number

Sex
MaleFemale

Relationship To Patient

Last 4 Digits of Social Security Number

Employer's Name
If you are employed please list your major employer's business name.

Employer's Street Address

City

State

Zip Code
Five Digit Zip Code

Employer Phone Number
Area Code Plus 7 Digit Number

Type of Position
Full TimePart Time

Responsible Party's Occupation

Person To Notify In Case Of An Emergency*
Please Type in Full Name, Relationship, Address, Area Code & Telephone Number

Insurance or Medicare/Medicaid Numbers*
Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.

Drug Allergies*
Please list all drugs and types of reaction

Do you Smoke?*
YesNo

If so:
How many packs? Years Smoking? Have you stopped? Would you like Cessation Education?

Do you use other Tobacco products?*
YesNo

If so:
What product? How long? Have you stopped?

Do you drink Alcohol?*
YesNo

If so:
How long? Last drink? Have you stopped?

Do you use illegal Drugs?*
YesNo

If yes, what kind?

Do you drink caffeine?*
YesNo

If yes, how much?

Family History
Please indicate if any of your blood relatives have or have had any of the following:

Check All that apply ?
GreatAIDS/HIVArthritisAsthmaBleeding DisorderBowel DiseaseCancerChemical DependencyDepressionDiabetesEpilepsy/ConvulsionsGlaucomaEye DiseaseHeart DiseaseHigh Blood PressureKidney DiseaseLung DiseasePsychiatric CareStrokeThyroid ProblemsTuberculosisOther:

If checked, please indicate the illness and your relationship to the relative.

Problem List
Please check all medical conditions you have or have had in the past:

Check All that apply?
ColitisCirrhosisCrohnsLupus ErythematosusMyastheniaMultiple SclerosisAlcoholismArthritisAsthmaAIDS/HIVAnemiaAnxietyBleeding DisorderBreast MassBronchitisBulimaClotting ProblemsCancerChronic PancreatitisChemical/Drug Dependent

Deep Vein ThrombosisBack PainBlood ClotsBreast CancerColon CancerDepressionDiabetes/Pre-DiabetesEsophageal DysmotilityEmphysemaEpilepsyFibromyalgiaGoiterGonorrheaGoutHeart MurmurHepatitisHerpesImmune System DisorderIrregular Heart BeatGallbladder DiseaseHeart Disease

Irritable BowelHeartburn/RefluxHiatal HerniaHigh Blood PressureHigh ColesterolHigh TriglyceridesHip ProblemsKnee ProblemsAnkle ProblemsFoot ProblemsInfertilityLiver DiseaseKidney DiseaseMigraines/HeadachesPace MakerPneumoniaProstrate ProblemsPsychiatric CarePulmonary EmbolismReaction to AnesthesiaRheumatic FeverSclerodermaSTDPolyscystic Ovarian SyndromeProstrate CancerShortness of Breath w/ExertionSleep ApneaStrokeThyroid DiseaseUrinary Stress IncontinenceUternine CancerVaricose VeinsSeizure DisorderSinus InfectionsSjogrens SyndromeStomach UlcersSuicide AttemptsThyroid ProblemsTuberculosisVaginal InfectionsVenereal DiseaseOther:

Surgical History*
Please list all surgical procedures you have had in the past. Include the name/type of operation and the year the procedure was conducted.

Preferred Pharmacy*
Please give name, location, and phone number.

Current Medications*
List Drug name, dose, frequency, route, and reason for taking. Include Herbal and Over the Counter Medications.