PATIENT REGISTRATION FORM

Please complete & provide insurance cards & photo ID to the receptionist so copies can be made.

Today’s Date: / / Social Security number: - - Date of Birth / /

Primary language: Need for translator: Yes No

(Circle one) (Circle one) (Circle one)

Mr. Mrs. Ms. Miss Male Female Single Married Divorced Separated

Patient Name:
Please print

Address:

City, State, ZIP:

Home phone: Work phone: Mobile phone:

If married, spouses name: If minor, parent or guardian:

If parent’s separated, with whom does patient reside? Mother Father Other (Name)

Are both parents entitled to information regarding the minor? Yes No (Provide documentation)

Are you a permanent Florida resident? Yes No

If no, provide alternate address:

Employer: Occupation:

Employer’s Address:

Emergency Contact: Phone: Relationship to patient:

COMMUNICATION ISSUES

Do we have your permission to:

Leave a message on your answering machine at home? Yes No
Leave a message at your place of employment? Yes No
Discuss your medical condition with a member of your household? Yes No
If Yes, whom? Relationship to patient:

INSURANCE INFORMATION

Name of insured: ID# Group #

Primary Insurance Company: Phone:

Billing address:

Secondary Insurance Company: Phone:

Billing address:

ID# Group #
 PATIENT HISTORY
Note: This is a confidential record and will be kept in your doctor’s office. Information contained here will not be released to anyone without your authorization

Date of last physical exam: / /

Reason for your visit today:

HISTORY OF PRESENT ILLNESS

Location of the problem

Head Neck Thorax Abdomen Other:

How long does the problem last?

30 minutes 1 hour It is always there Other:

On a scale of 1-10, with 10 being the most severe, what best describes the severity of the problem?
1 2 3 4 5 6 7 8 9 10

Is there anything else occurring at the same time?

Yes No If yes, please explain:
Nausea Rash Headaches Other:

When did you first notice the problem?

2 days ago 2 weeks ago 1 month ago Other:

Is the problem constant or variable?

Dull then sharp Very sharp then leaves Always there Other:

Does anything help or make the problem worse?

Moving around Standing up Lying on my side Other:

Does the problem interfere with your normal functions?

Yes No If yes, please explain:
Comments/Notes:

ADULT HEALTH HISTORY

Purpose of initial visit:

ALLERGIES FAMILY HISTORY

Drug:________________________________
Use check () mark for Yes answers
Food:________________________________
Other:_______________________________
Father Mother Father’s Mother’s Siblings Children
Parents Parents
Prescription:  No  Yes – please list Cancer
Diabetes
Glaucoma
Heart Disease
High blood pressure
Kidney disease
Mental illness
Stroke
Over-the-counter:  No  Yes – please list Thyroid disease
Drug or alcohol addiction
Epilepsy/convulsions

PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS

Please circle is you have had any problems with or are presently experiencing of any of the following:

High blood pressure Pneumonia Hemorrhoids Low back problems

Diabetes Persistent Cough Gall Bladder disease Skin diseases
Cancer Tuberculosis Weight loss Blood disorder
Heart disease Abdominal discomfort Colitis Venereal disease
Chest pain/chest tightness Hay fever Hepatitis or Jaundice Anxiety
Shortness of breath Indigestion Thyroid disease Depression
Swollen ankles Nausea Head or neck radiation Anemia
Palpitations Vomiting Headache Alcohol abuse
Lightheadedness Constipation Kidney disease Drug abuse
Frequent urination Diarrhea Kidney stones Changes in bowel habits
Rheumatic fever Blood in stool Difficult urination Asthma
Ulcers Arthritis Bronchitis Gout
Other(s):

Please list and supply the dates of

Operations:  No  Yes – please list

Hospitalizations other than for surgery:  No  Yes – please list

Transfusions: – please list

Immunization history- have you had:

Pneumovax:  No  Yes When? Flu:  No  Yes When?
Hepatitis A:  No  Yes When? Tetanus:  No  Yes When?
Hepatitis B:  No  Yes When? Other:  No  Yes What &When?

When was your last:

Complete physical Date: Result: TB test Date: Result:
Cholesterol check Date: Result: Eye exam Date: Result:

Hearing test Date: Result: Prostate exam Date: Result:

Stool check for blood Date: Result:
 FOR WOMEN ONLY – GYNECOLOGICAL AND OBSTETRIC HISTORY

Age at onset of periods: Frequency: Average Length of period:

Date of last menstrual period: Result: Number of Pregnancies?
Date of Last Pap Smear: Result: Births? Miscarriages?
Date of last Mammogram: Result: Abortions?
Have you experienced any
Prolonged abnormal vaginal bleeding  No  Yes Describe
Leakage of urine  No  Yes Describe
Pelvic pain  No  Yes Describe
Abnormal discharge  No  Yes Describe
History of abnormal Pap smear  No  Yes Describe
PREVENTION
Do you wear a seat belt?  No  Yes If not, why not?
Do you wear a bike helmet?  No  Yes  N/A
Do you drink beverages with caffeine?  No  Yes If yes, how many per day?
Do you smoke?  No  Yes If yes, how many per day?
Do you drink alcohol?  No  Yes If yes, how much per week?
Do you use drugs?  No  Yes If yes, what do you use?
Is there a firearm in your home?  No  Yes If yes, is it unloaded & out of the reach of children?  No  Yes
RISK HISTORY
Are you currently sexually active?  No  Yes If yes, how many partners have you had in the past five years?
Have you ever experienced:  No  Yes Sex with an injecting drug user?  No  Yes
Sex with a same-sex partner?  No  Yes Sex with a person with HIV/AIDS?  No  Yes
Sex while using drugs?  No  Yes Sex with a person with other STD(s)?  No  Yes
Sex for drugs/money?  No  Yes Sexual assault?  No  Yes
What method of contraception
do you use/have used most recently? Other contraceptive methods used?
Have you ever experiences problems
with any contraceptive method?  No  Yes If yes, what was the problem?
Have you been in contact with a person with confirmed TB?  No  Yes If yes, explain
Are you from or have recently traveled to regions of the  No  Yes If yes, explain
world with TB prevalence?
Are you currently or have you had recent contact with any of  No  Yes If yes, explain
the following?
HIV positive person Homeless person
Migrant farm workers IV/street drug user
Residents of nursing homes
Institutionalized/incarcerated persons
Have you ever worked with chemicals, paints, asbestos or  No  Yes If yes, explain
other hazardous materials?
Do you have a “living will”?  No  Yes If yes, explain
Do you have a donor card?  No  Yes If yes, explain
Patient signature (or parent/guardian):