2021 Adler Family Practice New Patient Registration

Adler Family Practice
New Patient Registration

*Required fields Errors may occur if these fields are empty.

Please note: Michelle Adler, NP is no longer accepting new Family Practice patients, she is only accepting Behavioral Health patients requiring Medication Management through her new practice, Adler Psychiatry New Mexico. Julie Gutierrez, FNP is accepting new patients now, and Ethan Adler, FNP is accepting patients on a wait-list basis until Summer 2026.

Name:

First NameMiddle Name/InitialLast Name

Birth Date

Date

Social Security Number

Please use format "1234567" with no dashes or dividers

Best Contact Phone Number:

.Format: (000) 000-0000.

This is a:

Secondary Phone Number, if any:

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

Confirmation Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance Plan ("N/A" if no insurance):

BCBS, Presbyterian, Medicare, etc

Primary Insurance Member ID ("N/A" if no insurance):

On your Insurance Card - NOT the Group ID

Secondary Insurance Plan ("N/A" if no Secondary Insurance):

BCBS, Presbyterian, Medicare, etc

Secondary Insurance Member ID ("N/A" if no Secondary Insurance:

On your Insurance Card, but NOT the Group ID

Preferred Pharmacy, please include cross-streets ("N/A" if you don't have prescriptions):

Note if you use a Mail-Order pharmacy. If not, please include cross streets, ex: "Walgreens at Montgomery and San Mateo"

Emergency Contact Name

First NameLast Name

Emergency Contact phone number

Format: (000) 000-0000.

Who is the emergency contact (spouse/partner, parent/child, etc)

Is there anyone else who you would like to authoriz to discuss your care, or access your medical information? (if so, a form for this will be provided at your first appt). If so, please provide name:

First NameLast Name

How did you hear about us?

Name of responsible party on the insurance plan:

First NameLast Name

Responsible party contact phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Responsible party birthdate:

MonthDayYear

Responsible party address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your relationship to the responsible party:

Employment Status:

Education:

Occupation (or retired, unemployed, etc).

Employer ("N/A" if not working, retired, etc)

Marital Status

Ethnicity

Gender Identity:

Sexual Preference:

Is there anything else you'd like to tell us about yourself? (Cool hobbies, interesting accomplishments, just moved here from somewhere, etc?)

Who was your last Primary Care Provider? Please enter "NONE" if you haven't seen a PCP in the past 10 years.

Enter "N/A" if you haven't been seen by a PCP in the past 3 years.

In the past 5 years:

Height & Weight

Is there something important or urgent to we need to address at your first appointment?

Personal Medical History:

Rows	Current Condition	Previous History	No History
Alcohol/Drug Abuse
Anemia
Anxiety
Arthritis (Rheumatoid)
Arthritis (Osteoarthritis)
Asthma
Bladder Issues or Diseases
Blood Clot(s)
Cancer, Breast
Cancer, Colon
Cancer, Other Type
Cancer, Ovarian or Cervical
Shingles
Cholescectomy or Gallbladder Problems
COPD/Emphysema
COVID-19
Depression
Diabetes, Type 1 (Juvenile/Insulin Dependant)
Diabetes, Type 2 (Adult Onset)
Diverticulosis or Diverticulitis
Fibromyalgia
GERD, Acid Reflux, Heartburn
Gout
Heart Attack and/or Stent Placement
High Blood Pressure / Hypertension
High Cholesterol / Hyperlipidemia
Medical Implants (Cardiac, Breast, Pumps, Joint Replacement, or other)
Irritable Bowel, Celiac, IBS, or Other Gastroenterology Conditions
Kidney Disease, History, or Single Kidney
Liver Disease or Hepatitis (A, B, or C)
Migraine
Neurological Condition
Osteoporosis
Pneumonia
Prostate Cancer or Enlarged Prostate (BPH)
Seizures/Epilepsy
Skin Conditions or Skin Cancer
Sleep Apnea or Insomnia
Stroke or other Brain Injury
Thyroid Condition
Currently using Medical Cannabis
History of Bariatric Surgery

Please enter any additional medical history information here:

Family Medical History (Check "No History" if none of these apply)

Rows	Mother	Father	Sibling	Maternal Grandparent	Paternal Grandparent	No History
High Blood Pressure
Heart Attack
Heart Disease, Other
Cancer, Colon
Cancer, Prostate
Cancer, Lung
Cancer, Ovarian
Cancer, Breast
Cancer, Other
Diabetes (Type 1 or 2)

Additional Family Medical History Information if any:

Please list your surgical history here (Enter "None" on first row if no surgical history):

Rows	Type of surgery	Year of Surgery
1
2
3
4
5
6

Additional Surgical History Information:

Please list your current medications (Enter "None" on top row if you don't take medications):

Rows	Medication Name	Dose	Frequency (once a day, twice a day, etc)
1
2
3
4
5
6
7
8
9
10

Additional Medication information:

Please list any additional Providers you see (Specialists, Alternative Practitioners, etc.) Enter "None" on top row if you don't have additional Providers:

Rows	Name	Type of Provider (Cardiology, etc)	Group, Hospital, or Clinic Name?
1
2
3
4
5
6
7
8
9
10

Additional Provider Information:

Do you have Allergies to any of the following? (CHECK "NO ALLERGY" FIELD IF NONE)

Rows	Mild	Moderate	Severe	Anaphylaxis	No Allergy to This
Aspirin
Codiene
Latex
Penicillin
Sulfa Drugs
Food or Peanut
Seasonal
Pets

Other Allergy Information:

Womens Health:

Rows	Yes	No	Additional Info
Number of pregnancies
Number of births
Number of miscarriages
Number of abortions
Age of onset of periods
Age at end of periods
History of hysterectomy? (Total or partial)
Have you used or are you currently using hormone replacement therapy?
Do you have a history of abnormal Pap or Mammogram exams?
Other Gynecological History?
C-Sectons
Have you had pregnancy complications?
Are you currently pregnant?
Are you currently trying to get pregnant?
Are you using oral contraceptives? (Please include on medication list above)
Do you use other contraception? (Please enter type in column on right)

Additional Womens Health Information:

Routine screening Information:

Rows	Year of last test	Some have been Abnormal (Y/N)	Have never done
Men 50 or older: Prostate Screen (PSA blood test)
Women 40 or older: Mammogram
Women 21 or older: Pap Exam
Women 65 or older: Bone Density Screen (DEXA scan)
Women or Men Over 45: Last Colonoscopy

Immunization History.

Rows	Year	Year	Year	I don't know when, but I've had it done.	HAVE NOT HAD
Tetanus (or TDAP)
Varicella (Chicken Pox vaccine or illness)
MMR (Measles, Mumps Rubella)
Annual Flu Shot
Pneumonia Vaccination
Covid Vaccination Series
Shingles Series
Hep A
Hep B
HPV Series

Tobacco Use

Rows	INFO
iF YOU CURRENTLY SMOKE TOBACCO
.....How long have you smoked?
.....How much do smoke per day?
IF YOU USED TO SMOKE, BUT QUIT
....How long did you smoke?
....How much did you smoke per day?
DO YOU USE OTHER TOBACCO PRODUCTS OR VAPE?
MARK "X" IF YOU'VE NEVER USED TOBACCO PRODUCTS:

Alcohol Use:

Rows
If you drink alcohol? (Mark "N/A" if you don't):
# of drinks per week, beer:
# of drinks per week, wine:
# of drinks per week, liquor:
Men, how many times in the past year did you have more than 4 drinks at a time?
Women, how many times in the past year did you have more than 3 drinks at a time?
I DON'T DRINK ALCOHOL

Activity Information:

Rows	Info
Do you exercise regularly? (Y/N):
If yes, what type of exercise (Cardio, Weights, Yoga, Etc):
How long (in minutes)?
How many times per week?

In the past 2 weeks:

Rows	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly Every Day (3)
Have you been feeling down, depressed or hopeless?
Have you had little interest or pleasure in doing things?

Safety:

Rows	Yes	No	Don't know
Does your residence have a working smoke detector?
Do you use seatbelts consistentlly?
Do you use a helmet for recreational activities (bicycling, skiing, skateboarding, etc)
Are there guns in your residence?
If yes, are the guns and ammuniction locked and stored separately?
Do you feel safe in your home?

To schedule your first appointment, we will need:

1. Your current Insurance Card (or Cards if you have secondary insurance) &
2. A Valid Identification Card

You may email them to us using this link: EMAIL US HERE or,
bring to the clinic, and will copy them for you.

Please note: For missed appointments, or if an appointment is cancelled with less than one business day's notice, we have a $100 missed appointment charge, not covered by insurance, that is required to be able to schedule another appointment with us.

By signing below, you are attesting that the information you provided above is correct and complete.

You may use your computer mouse to sign below.

Signature

Heads up:
SOME GPS SYSTEMS & GOOGLE MAPS MAY NOT PROVIDE OUR CORRECT LOCATION!

1. We're on Montgomery, west of Womens Hospital between Jefferson and Carlisle, in the
Granada Square office complex.
2. We're located behind Cocina Azul restaurant, "all the way back, then all the way left"

Your Demographic Information

Responsible Party Information

Other Information

Medical History