Patient Registration & History

Please complete all applicable fields. Required fields are marked with *.

Patient Registration

Date*

Patient Name (First, Middle, Last)*

Date of Birth*

Home Address*

Apt #

City*

State*

Zip*

Age

Sex*

Social Security Number

Tip: you can leave this blank if not required by your workflow.

Cell Phone*

E-mail

Marital Status

Why are you being seen today?*

Emergency Contact

Name*

Relationship*

Home Phone

Cell Phone*

Health Insurance Information

Policy Holder

Policy Holder DOB

Policy Holder SSN

Policy Holder Address (if different)

Policy Holder Phone # (if different)

Patient History

Patient’s Name

Date

Medication Allergies

Reaction

Food Allergies

Reaction

Current Medications (including OTC, vitamins, supplements)

#	Medication / Supplement
1
2
3
4
5
6
7
8
9
10
11
12

Major Surgeries

Surgery	Date

Family History

Relation	Living/Deceased	Age	Major Health Problems
Father
Mother

Social History

Do you use Tobacco Products?

If yes: cans/packs per day, for years/months

Are you a former tobacco user?

If yes: years/months ago

Do you use drugs (e.g., Methamphetamines, Marijuana, Cocaine, Heroin, Steroids, PCP, Acid, inhalants)?

If yes: what substance, times per week

Do you drink Alcoholic beverages?

If yes: per day / week / month

Do you exercise?

If yes: minutes, times per week

Do you drink caffeinated beverages?

If yes: cups per day

I confirm the information provided is accurate and complete.*