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Secure Form :: Pre Registration
** Required Fields

PATIENT INFORMATION

Last Name **
First Name
Middle Name
Date Of Birth
Height
Weight
If the patient is a child; Whom they live with ?
Is the home smoke free ?
Gender
Marital status
Social Security Number
Address
City


State
Zip
Phone (Home)
Phone (Work)
Phone (Cell)
Email Id
Race
Hispanic
Language
Reason for visit
Spouse Name (If Married) Or
Parent Name (If Child)
Spouse/Parent
Date Of Birth
Spouse/Parent
Social Security Number
Primary MD
Address
Phone Number
Referring MD
Address
Phone Number

MEDICAL INFORMATION

  Allergies  
Not Known Sulfa Penicillin Codeine
Latex/tape IV contrast/Iodine Other
  Past or Current Medical History  
Asthma/COPD Seizure/Convulsions Mental illness Heart problems
High blood pressure Bleeding tendency High cholesterol Diabetes
Stroke/heart attack Thyroid disorders Acid reflux/GERD Radiation to neck
Headaches Arthritis Hearing Difficulty
Cancer Other
  Past Surgical History  
None Tubes Sinus Adenoids or Tonsils
Thyroid Mastoids Cardiac surgery Gallbladder
Tracheostomy Appendix Heart Varicose Veins
Breast-Lumpectomy/Mastectomy Other
  Pharmacy  
Name
Local
Mail Order
Current Medications (Name/Dose, Name/Dose, ...)
  Past Family Medical History  
  Father Mother Brothers(s) Sister(s)
Thyroid cancer
Head/neck cancer
Cancer, Other:
Asthma/Allergies
Hearing loss
Diabetes
Heart Disease
Bleeding Disorders
High Blood Pressure
Stroke, Other:

SOCIAL INFORMATION

Social History Recreational Drugs Social History Alcohol Social History Tobacco

Tobacco Pack per day  
  Social History Occupation  
 Patient occupation      Veteran

REVIEW OF SYSTEM

  Constitutional Symptoms  
Good general health lately Recent weight change Fever
Fatigue Headaches  
  Skin  
None Itching Rash Lesion
Lump Skin Cancer Bump Laceration
Other  
  Eyes  
Wear glasses Wear contact lenses Blurred or double vision Glaucoma
  Ears/Nose/Mouth/Throat  
Ringing in ears Difficulty Hearing Hearing test within last 2 yrs
Earaches or drainage Chronic sinus problems Nose bleeds
Bleeding gums Sore throat Hoarseness
Difficulty swallowing Frequent ear infections Loss of taste
   Cardiovascular  
None Chest pain Palpitations/Irregular heart beat Heart Attack
Pacemaker Other  
  Pulmonary  
None Asthma/wheezing Shortness of breath
Breathing difficulty Sleep apnea/disturbance Other  
  Gastrointestinal  
None Abdominal pain Diarrhea
Difficulty swallowing Heartburn Nausea
Loss of appetite Vomiting Other  
  Genitourinary  
None Kidney stones Rash/itching Other  
  Musculoskeletal  
None Osteoporosis Arthritis Back Pain
Other  
  Neurological  
Weakness Seizures Dizzness Unsteady Gait
Fainting Other  
  Endocrine  
Heat/cold intolerance Other  
  Psychiatric  
None Depression Abnormal Sleep
Anxiety Memory loss/confusion Other  
  Hematologic  
None     Easy bruising     Past blood transfusions     Exposure to HIV / AIDS    
Is this due to an injury ? Date Of Injury
Workers compensation claim  

INSURANCE INFORMATION (PRIMARY)

Name of Insurance Company
Who holds insurance for the patient ?
Name of Subscriber
Date Of Birth
Social Security Number
Address
City


State
Zip
Employer
Address
Phone
Policy or ID Number
GroupNumber
 

INSURANCE INFORMATION (SECONDARY)

Name of Insurance Company
Who holds insurance for the patient ?
Name of Subscriber
Date Of Birth
Social Security Number
Address
City


State
Zip
Employer
Address
Phone
Policy or ID Number
GroupNumber
 

OUR PRIVACY POLICY

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