NEW PATIENT REGISTRATION
Patient Legal Name
First Name
Last Name
Date of Birth
*
Sex assigned at birth
*
Please Select
Female
Male
Intersex
Gender identity
*
Please Select
Masculine/man/young man/boy
Feminine/women/young woman/girl
Non-binary
Agender
Questioning
Prefers not to state
Provider has yet to broach the topic
Transgender?
*
Please Select
No
Yes
Questioning
Prefers not to state
Provider has yet to broach the topic
Race
*
Please Select
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Ethnicity
*
Please Select
Not Hispanic, Latino/a, or Spanish origin
Hispanic, Latino/a, or Spanish origin
Unknown
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone #
*
Social Security #
Email Address
*
Place of Birth
*
Education Level
Current Student?
Yes
No
If so, grade level?
Marital Status
*
Married
Single
Divorced
Other
Employed
Employed
Retired
Unemployed
Other
Employer
Employer Phone #
Occupation
Preferred Language
Interpreter Needed
Sign
Speech
N/A
Do you have any mobility difficulties requiring assistance(ie: wheelchair)?
Yes
No
EMERGENCY CONTACT
Name
Relationship
Phone
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PRIMARY INSURANCE
Type of Insurance
*
Medicaid
Medicare
Commercial
Uninsured
Primary Insurance
Subscriber Name
Insurance ID #
Group #
Effective Date
DOB
Social Security #
Subscribers Address if different from mailing:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscribers Relationship to Patient
Employer
Picture of Primary Insurance Card
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Picture of Driver's License or Photo ID
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of
SECONDARY INSURANCE
Secondary Insurance
Subscriber Name
Insurance ID #
Group #
Effective Date
DOB
Social Security #
Subscribers Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscribers Relationship to Patient
Employer
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ALLERGIES (Medication/Food/Environmental)
Substance
Reactions
*
No primary care provider identified
I have a primary care provider - Write Name below
Name of Primary Care Provider
HEALTH MAINTENANCE
Date of last exam
Diabetic Eye Exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diabetic Foot Exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Colonoscopy
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pap
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mammogram
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PRESCRIPTION MEDICATION/SUPPLEMENTS
Name
Dose
Times per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
Name
Dose
Times Per Day
Prescribing Provider
FAMILY HISTORY
Rows
Living
Age at Death
Current Age
Medical Problems
Father
Yes
No
Mother
Yes
No
Brother
Yes
No
Sister
Yes
No
Child#1
Yes
No
Child#2
Yes
No
Child#3
Yes
No
MEDICAL HISTORY
(Surgeries within the Year: Major Illnesses/Injuries; Etc…)
High Blood Pressure
High Blood Pressure
High Cholesterol
Diabetes
COPD/Lung Disease
Heart Disease
Kidney Disease
Cancer
If Cancer, type of cancer
Other
Current Smoker
Yes
No
If current, what type and how much?
Former Smoker/User
Yes
No
Are you interested in quitting?
Yes
No
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