Forms Step 1 of 9 - Basic Information 11% Basic InformationName Date MM slash DD slash YYYY SSNBirth date MM slash DD slash YYYY Sex Male Female PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Marital Status Minor Married Widowed Divorced Separated Email Employer Work PhoneIf a student, name of school and addressAgeHeight WeightShoe Size Emergency Contact Phone Insurance InformationWe will need a copy of your insurance cards before being seen by the physicianName of person responsible for this account Relationship to Patient Policy Number Group Number SSNBirth Date MM slash DD slash YYYY PhoneList the name of each of your insurance carriers Confidential New Patient QuestionsWhat problems bring you to our office?What treatments and self help or over the counter products have you used to help these problems?Who referred you to our office? Who is your primary Care Physician? Date of last physical MM slash DD slash YYYY Medical History (select all that apply) Accident/Injuries Anemia Asthma BleedingDisorders Bronchitis Cancer Diabetes Depression/Anxiety DVT epilepsy/Seizures Foot Problems Gout Heart Attack Heart Disease High blood pressure Kidney or Bladder Disease Liver Disease Rheumatic Fever Stomach Ulcer/Reflux Thyroid Disease Vascular/Circulatory Other Surgical HistoryListOperationDateHospitalSurgeon Family HistoryFather Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Mother Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Brother Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Sister Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Son Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Daughter Arthritis Cancer Diabetes DVT Heart Trouble High Blood pressure Kidney Disease Mental/Emotional Disease Reaction to Anesthesia Stroke Social HistoryWho do you live with? Parents Spouse Children Significant Other Alone How many children do you have? Are you currently? Employed Unemployed Disabled Occupation (current or former) How many caffeinated beverages do you drink per day? (coffee, cola, tea) Do you participate in regular exercise? Are you a competitive athlete? Do you now, or have you ever smoked? How much per day and how long? If you no longer smoke, when did you quit? Do you now, or did you ever drink alcohol? How much? Do you now, or have you ever used recreational drugs? Which drugs and how much? If you no longer use drugs, when did you quit? ROSConstitutional Symptoms fever chills night sweats fatigue recent weight loss/gain Cardiovascular cold feet irregular or fast heartbeat pain in calves swelling in feet/ankles/hands Endocrine heat/cold intolerance excessive thirst or urination Ear, Nose, Mouth, Throat difficulty swallowing ear infections/drainage hearing loss or ringing hoarseness loss of balance nasal stuffiness neck pain/stiffness nosebleeds sore throat/tonsils swollen glands in neck Eyes blurred/double vision dry eyes wears glasses/contacts Gastrointestinal abdominal pain bloating blood in stool change in bowel pattern constipation frequent diarrhea gas heartburn loss of appetite nausea/vomiting rectal bleeding Genitourinary blood in urine burning or painful urination change in force/flow frequent urination Skin acne dermatitis hives irregular moles rash/itching ulcers warts Hematologic/Lymphatic slow to heal after cuts phlebitis/blood clots Males difficulty urinating penile discharge testicle pain testicular/scrotal mass Musculoskeletal/ Neuromuscular burning in feet/legs hip/knee/low back pain joint pain/stiffness muscle aches/cramps numbness feet/legs weakness of muscle/joints Neurological convulsions/seizures frequent recurring headaches light headed/dizzy numbness or tingling Psychiatric chemical dependency depression memory loss/confusion suicidal thoughts Respiratory asthma or wheezing cough phlegm shortness of breath snoring at night spitting up blood Females breast pain,mass or discharge heavy bleeding irregular period prolonged period severe menstrual pain vaginal discharge are you pregnant Date of last period Is there anything you wish to tell the physician privately? Yes No MEDWhich Pharmacy do you use? Please list all the medications you are currently taking (include birth control pills, insuline, aspirin, and all over the counter medicines)I am allergic to (include medicines, foods, pollens, latex, etc.), and what type of reaction you had: Notice of PrivacyElectronic Signature - Please type your full name below to indicate your agreement:* I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.Date MM slash DD slash YYYY Information and assignment of BenefitsElectronic Signature - Please type your full name below to indicate your agreement:* I authorize the release of any medical information necessary to process any of my claims. I permit a copy of this authorization to be used in place of the original.Electronic Signature - Please type your full name below to indicate your agreement:* I hereby authorize the physicians of this company to apply for benefits on my behalf for covered services rendered by them or by their order. I request that payment from my insurance company be made directly to the physician. I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked be either me or my insurance company at any time.
