Name of your practice here

(First Encounter)

 

 

Today’s Date 07/10/05 08:38:12 PM

Last Name First MI

SS Number (No Dashes) Date of Birth E-mail (if any)

Address 1

City State Zip

Tel (Home) Tel (Work)

Marital status (optional):  Significant other Single Married DivorcedWidowed SeparatedDon’t ask !!

Name of spouse For Minors(Name of Guardian)

Health Insurance   Check here if None or self pay

Name of Primary insured member

Member ID number Group number

EmployerPreferred pharmacy Location

Pharmacy telephone(if Known)Who may we thank for your referral

Emergency contact personTelephone of emergency contact

Enter a password that only you can give someone to authorize them to get information on you. Please note that this is to facilitate information access in this world of confidentiality. Please note that this gives access to information about you so please be very careful as to who you give it to.

Have you seen any of our doctors as a patient before? Yes No

My signature below indicates my consent to any and all of the medical services provided to me by the office of Dr. Your name here. I agree that I am financially responsible for all the charges regardless of my insurance status and that this office will file my insurance as a courtesy only. Further I authorize the release of any medical information necessary for my care or financial concerns.I also understand that I may be called by the authorized billing company for this office to confirm details about my balance and other  insurance information.

Signature Please fill out other page too

______

 

Name of your practice here

(Health questionnaire)

Your Full Name:______________________________________________

Allergies to medicines

__________________________________________________________________________________________________________________________________________________________

o Check here if none of the following conditions apply to you

Check the problems you may be facing now or in the past:

Do you smoke o No o Yes How many packs a day___ Since when______

Do you drink alcohol o No o Yes How many drinks a week___ Since when_____

o Angina

o Arthritis

o Appendicitis

o Blood clots

o Bypass surgery

o Back pain

o Cancer

o Chest pain

o Cholesterol elevation

o Colitis

o Coronary artery disease

o Depression

o Diabetes

o Ear infection

o Gall bladder problems

o Headaches

o Heart attack

o Heart failure

o High blood pressure

 o Impotence

o Insomnia

o Kidney problems

o Loss of consciousness

o Migraine

o Rheumatic fever

o Seizures

o Stomach ulcers

o Stroke

o Vision loss

o Any other problem Specify_________________

__________________________

What surgeries (if any):

________________________________________________________________________________________________________________________

Please list your Current Medications here: