New Patient Paperwork 1
Please read each section carefully and initial.
Patient Registration
Name
*
First Name
Middle Initial
Last Name
Preferred Name
Referring Physician
*
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Cell Number
*
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Sex
*
Male
Female
Other
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Primary Care Physician:
*
Spouse Name
Spouse Phone
-
Area Code
Phone Number
Referral Source
Ad/Mailer
Friend/Family
Hospital
Online
Phone Book
Provider Network
Other
Preferred Pharmacy
*
Pharmacy Phone Number
*
-
Area Code
Phone Number
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship
*
Back
Next
Past Medial History
CARDIAC HISTORY If checked, when:
Rows
Yes
If yes, when?
Heart Attack
Bypass Surgery
Angioplasty / Stent
Treadmill Echocardiogram (Cardiac Ultrasound)
Irregular Heart Rhythm
Congenital heart disease
Heart Murmur
Pacemaker
Rheumatic Fever
Stroke / TIA Congestive
Heart Failure
RISK FACTORS When Onset:
Rows
Yes
If yes, when?
Hypertension
Diabetes
Elevated Cholesterol
Kidney Disease
Thyroid Disease
Cancer
Anemia
Bleeding Problems
Eye Problems
Weight Loss
Head / Nose / Mouth
Lungs
Gastrointestinal
Skin
Neurological
Psychological
Musculoskeletal
Stress
REVIEW OF SYSTEMS (Check All That You Have Been Treated For)
*
Rows
Yes
No
If yes, when?
Chest Pain
Shortness of Breath
Ankle Swelling
Dizziness
Fainting
Other
SURGERIES / HOSPITALIZATIONS
Rows
Surgery or Hospitalization
Date
Location
Physician Comments
1
2
3
4
5
6
Back
Next
FAMILY HISTORY - Relation Alive Significant Health Problems (Mark All That Apply)
*
Rows
Yes
No
Gender
Heart Attack/Heart Disease
Heart Surgery
High Cholesterol
High Blood Pressure
Stroke
Heart Failure
Age at Onset or N/A
Father
Male
Female
Mother
Male
Female
Sibling
Male
Female
Sibling
Male
Female
Child
Male
Female
Child
Male
Female
REVIEW OF SYSTEMS (Check All That You Have Been Treated For)
*
Rows
Past
Present
Never
How many drinks per day?
Do you use alcohol?
*
Rows
Past
Present
Never
How many packs per day?
Do you use tobacco?
*
Rows
Past
Present
Never
Please Explain
Exposed to secondhand smoke at home?
*
Rows
Yes
No
Type
Frequency
Do you exercise?
*
Rows
Yes
No
How many drinks per day?
Consume caffeine, tea, soda?
*
Rows
Unrestricted
Low Fat
Cholesterol
Low Salt
Other:
Dietary Pattern:
Submit
Should be Empty: