PATIENT REGISTRATION F`ORM Spouse_ Parcnt --

PATIENT REGISTRATION F`ORM Spouse_ Parcnt --

PATIENT REGISTRATION F'ORM
MED EDGE "MRN'NO:
PATIENT INFORMATION: {Please
use
full legal name, no nicknames)
*Last Name:
*First Name:
Middle Initial:
*Address:
City:
Zlpz
State:
L_J
Home Phone #:
*Social Security #:
_______-.
*Date of Birth:
*Sex:
Age:
_
Marihl Status:
_
Drivers Lic#:
*Employer Name and Address:
Work Phone #:
E mail Address:
Cell Phone #:
Emergencv Contect Name:
Pleusetellus howyou
(___-J
L___)
,
.
:
Phone #:
heardaboutas:
Refenedbv
GUARANTOR-tr\IFOR{l{A:EION*{,ist-person-orinsuredJrameresponsible{or-biH--use{ull{egalTame-no-nicknames}---'
*Relationshlp ofGurrantor to
Paticnh
Self_
*Lrst Name:
Spouse_
Other
Parcnt
--
*First Name:
.
Middle Initirl:
*Address:
City:
zip:
State:
Home Phone #:
*Social Security #:
L_-)
*Drte of Birth:
*Sex: Female
Age:
Male
*Employor Name and Address:
Work Phone #:
INSURANCE INFORMATION: @lease allow receptionist to photocopy your insurance ID cards)
IF SOMEONE OTHER THAN PANENT IS THE INSARED PARTY. PLEASE INCLADE DATE OF BIRIII FOR CI.AIMS
PRIMARY INSI]RANCE:
Plan Name :
*Insuredts Name:
fnsured's Social Security #:
*Insured's Date of Birth:
*Policy I ID #:
*Group #:
Eff Date:
Claims Address & Phone:
SECONDARY INSURANCE:
Plan Name:
*Insuredts Name:
*Insured's Social Security #:
*Insured's Date of Birth:
*Policy / ID #:
Claims Address & Phone:
*REOUIRED FIELDS-PLEASE COMPLETE FOR
Confi dcntial MEHG
hopriclary Infomation
*Group #:
BILLING.
* Eff Date:
*ATTACH COPY OF INSURANCE CARDS.
New Pt Reg Fom
Dc
2004
t1
tl
Fcrtlenl
Adutt Medlcal Hlstory
AOe _
llorne
Todo/s Dcle
_
Hlstoryhfonnollon $Jppll€d bV:
tr
Bkth Dote
tr Other
Sef
\ryhy is pollenl here todoy?
b polient cf,erdc lo or hod
qt odvene reocllon lo orry nredcofbns.
h potient tokhg my gescdptlon
rnoclicotlrns? DYos fl llo f 1,ras, lst
Doleof
lostprcsloteexcrn--
Fomaler
A€p of lsl menstuol
l-
Hos
pollenl
I
$€l fi$ or 6res? O \bs D l,lo f Wc tst,
tr poll€nt tddng orry nonfiescdtctlon
rnedcqfions (foroxornple, osffi or
vilorrlns)? D \bs D No lf yes, lsL
lbs pollent hod anyrnolor srrgerbs?
DYesDNo fyos,lsL
EverlpclosorudVtonsrnlttedcllseose? fl\bs
p€dod
Ff$ dcry of losl rnenslrud
perlod
DNo
tbecondorrs? DYes ONo
tength of menslruol pedod
dlseose? nEs-n Ho
l.lomol? D\bs trl,lo Doleof lostrnonynogrom? Nonrun O\|as trt'lo
esnodl senffinsrrneo
Doleolloslbsn€cr
I
lbods.
Health Hirtory
gm@cr€nts. $IngF, or ctilklren hocl o( hore orry of the fidbwlncf Check ol thot oppV.
Mloril Fqrfv
Follert FfffV
l{os potl€nt porents,
Cstcer D
Stoke D
Arltull's tr
D
Slclrle Cel
Ttlcerculods D
A$rrno tr
Hepolills D
Diobetes D
Heodoches D
l-IghChdested
Dseose
Dlseose
Ifryrold Dlseose
Elood Dlseose
tvl€ntol Disodets
Selztre tlsoder
hluscle RoUerns
Erqchysemo
D
D
Skh
Fleod
tr
tr
D
D
D
D
tr
E
O
CI
O
D
tr
D
X
CI
Ch€ck lhe fdlovthg cHklhood llnesses the pollenl hos trod.
D Meosbs D Munps D CNcken
n Wfrooplng
bx
Does pollent we lobocco? tr Yes
Type: DClgotetle fuc*sperdoy
Slornrch
U
D
Bone/Joht
l&ft€,V/Blockler
tr
O
tr
tl
tr
tr
O tr
U D
O tr
D D
O tr
O tr
tl D
D O
CID
Cotrgh D Tondlilis D Eq lnfeclions
D atit
!€(rs ogp
E Olher
for
Flospollenteverus€dstreetdrugs? DYes
Foblerrs
Fobbms
Foblems
GlorcomdCoicrocts
llgh Bloocl fisssure
Bleectng ProUerns
Itpurnollc Fevq
Olher _
n
DNo lf yegtlpe: DCocohe
DlUoriJuono Elnhokrnls DOfher
llpe: O Eeer D
Doespolientdrhkolcotro0 OYes BNo trQrlit_!€orsogo
How ollen dct or does poflent ddnk? tr SeHorn O Sornethnes tr Weekty D Do[y
Wine D
Uquor
l-low oflen? E SelJorn D Sornelirnes D We€kV D DoiV
No Whot fpe?
tr 15-30 rr{rutes tr 30 or rtore
l-bwrrnnycofleinedinksdotonddnkperdof tl I -2 El3 -4 D 5orrnote
Do you exercise? E Yes D
How long? D 0 -15 rnlnutes
Wlll)?
Do you have an Advanced Directive (Livlng
Do you wish to discuss an Advanced Directive (Living
CL-006 (5-13-96) Rev.
t0-00
Yes --No
Yes
Wlll)?
Form;
Signalure of Person Gompleting
-
-No
63
Western Center Family Medicine
PatientName:
DATABASE TOOL
Date:
Sex:
M/F.
Race:
For what reason are you here today?
Please check conditions you have experienced recently or that concern you:
GENEML
E good general health
I always tlred
I always feel ill
I chronic htigue
E loss of appetite
fl wt loss > l0 lbs
E wtgain > l0 lbs
E :bT'J:"lrever>r00o
E chilts
HEENT
pain
drainage
"y"
l--_EI :v*ry eyes
I
eye
E
iI
f,:l?l]**
H
E double vision
light flashes
fl=91":I"':l:"
D lossofvision
E ear pain
E eardrainage
_E
;:il'ff'[:,
f] runny nose
E nasaicongestion
E nose bleeds
[1 hay fever
fl sinus pain
fl frequent sinus infections
fl freguent colds
E recent change in voice
I freguentso.lthro.,r
E ho".r"no,
fl laryrgitis
E swd[wing pain
HEARTAND
CIRCUIATION
I chest pain
E palpitations
tr shpped hean beats
E extra heart beats
E fast heart beats
tr high blood pressure
I calf pain / calf cramps
I ankle swelling
E blood clot in veins
I
cord,
purprefeet
RESPIMTORY
I shonness of breath
E *h"*ri
E cough
I coughing blood
I snoring
I sleep apnea
E fluid in lungs
BREAST
rash
I
tr change in skin color
tr dry skin
I itching
B .unusual or changed moles
E boils
I skin growths
SKIN /
unexplained
g il"il3,:'lrl|;1t
;;.o*.rrl'.rer'
nausea
fl
persistent
unexplained
vomiting
I
fl frequentheartburn
fl abdominal bloating
tr swallowing difficulties
u abdominal cramps
H
;i:l;il:,.
g::Y1l*lfi-.
fl consant constiPation
E change in bowel habits
I bleedingfrombowels
E anal / rectal pain
E hemorrhoid
E [',,'J"1il:l'"",'*t
,aENrr,-\r
rr
GENIToURINARY
painful
urination
E
controlling urine
H
urinate > 2 times at night
I :::_t:
! blood. in urine.
E testicle lump / swelling
E penile discharSe / sores
! irregularperiods
tr heavy periods
E noperiods.
I vaginal discharge / itching
! possibly pregnant
Epain"rittrser ,
fl lack of sex drive
fl no erection / orgasm
MUSCULoSKELETAL/
n*:"'t'lt
, .,.
paln / strnness
lJ
g"ner"i
EJ 'olnt: #;ff"t
E pain: ""tn i;:"tl'"""
f1 pain' r'ip I t"l"Jlr""t
! pain: tnt''i"t l'"'il*
rD
p"in,,".i,t7-t,*i'--"
|'
NEUROLOGIC
I frequentheadaches
E Ur"Jt "" /r"r"u"e
fr aizy or light headed
E
poo,.
ua"i."
Ef
E
E
fi'',1',1*%?!",.
I
E
ft
E
I'y.:
Ef hayfever
infections
E ;il;;inu,
tr frequent foreign ravel
seizures
numbn"r,
E::m*;ii|"ol,oo,,o,
Erecurrentskininrections
MlscEu-ANEous
E
chemicalexposures
E
ffi:.iJig:::,"
fl
I
I
f]
fl
Emostalwayscold
most always hot
oven'rreight
abnormal hairgrowth
h"i.
occupation"i oporu.",
shk pets
drink well water
drink unpasteurized milk
process own meats
OTHER
ENDOCRINE
to*
!.l change in skin color
excess thirst
E
excess urination
H changes in ring' hat' shoe size
H
E irregular menstrual cycles
H
to medicines
to cosmetics
allergiestofood
allergies
allergies
problems
loss of strength
speech
H'"'J,'flo'
E
easy bi"uising
tr lymph node swelling
tr swollen e)dremit],
lf;:I*"'n'*
I depressed
I hyperactive
E attention deficit
E excess: fear / worry
I bss of interest in life
tr suicidal thoughts
E unusual visions
I difliculty concenrating
I difflcultygeaingtosleep
E difticulty iayin! asleep
tr impulsive
I
I
E
/
HEMATOLOGIC
blood ransfusion
, E free bleeder
rNg=crrous ose,qsE
E
Ememorvtos.
I
E
E
LYMPHATIC
il:;t;{il**t'*
-