Microsoft word - patient information health history.rtf

PATIENT REGISTRATION FORM

Patient's Name ______________________________________________________________
Today's Date: __________________
Single Married Divorced Minor Male Female Age _____ Birthdate _________ Social Sec. No.___________________ Street Address: _____________________________________________ Telephone: HOME ________________WORK_____________________ City: ___________________________State_____Zip_______________ Patient/Parent employed by:____________________________________ Driver's License No:__________________________________________ Employer's Address:__________________________________________ Present Complaint: __________________________________________ Position/Occupation:__________________________________________ Who referred you to this office? ________________________________ Spouse/Parent's Name: _______________________________________ Referring doctor's name & phone _______________________________ Spouse's Social Sec. No. ______________________________________ Contact Person not living with you ______________________________ Spouse's Employer:___________________________________________ Address & Phone: ___________________________________________ Spouse's Position/Occupation: __________________________________ Who is responsible for this account? ____________________________ Insured's Name _____________________________________________ Insured's Name ______________________________________________ Insured's Date of Birth _____________Soc.Sec. No.________________ Insured's Date of Birth _____________ Soc.Sec. No._______________ Name of Insurance Co. _______________________________________ Name of Insurance Co. ________________________________________ Address____________________________________________________ Address____________________________________________________ Phone:____________________Plan/ID No.:_______________________ Phone:_____________________ Plan/ID No.:_____________________ Secondary Insurance Coverage Information: Insured's Name _____________________________________________ Insured's Date of Birth _____________Soc.Sec. No.________________ Insurance Workers Comp Credit Card Cash/Check Name of Insurance Co. _______________________________________ Medicare Medicaid ID NO.:______________________________ Address____________________________________________________ Other: ___________________________________________________ Phone:____________________ Plan/ID No.:______________________ PLEASE ANSWER ALL QUESTIONS BY CIRCLING YES (Y) OR NO (N)
8. Are you using or taking any of the following? 2. Has there been any change in your general health in the past year? 3. Date of last physical exam: ___________________________ 4. Are you now under a physician's care for a particular problem? If yes, for what? ______________________________________________ 5. Have you had any serious illnesses, operations or hospitalizations? describe:________________________________________________ ____________________________________________________________ 6. Have you had any adverse effects from dental treatment? 7. Do you have or have you ever had any of the following: I. Digitalis, inderal, nitroglycerin, calcium blockers, procardia or A. Rheumatic fever or rheumatic heart disease? J. Aspirin or ibuprofen (motrin, naprosyn, etc)? C. Cardiovascular disease (heart trouble, heart attack, heart How much daily? __________________________________________ murmur, coronary artery disease, angina, high blood pressure, K. Antihistamines or other decongestants (seldane, etc)? stroke, palpitations, heart surgery, pacemaker installed)? L. Drug(s) to assist in weight loss or weight gain? D. Lung disease (asthma, emphysema, chronic cough, bronchitis, M. Any other medications, pills or drugs, including “street drugs? pneumonia, tuberculosis, shortness of breath, chest pain, If yes, please specify:______________________________________ 9. Are you allergic or have a bad reaction to: E. Seizures, convulsions, epilepsy, fainting, psychiatric treatment, dizziness, nervous disorder or breakdown? B. Penicillin, amoxicillin, cephalosphorins or other antibiotics? F. Bleeding disorder, anemia, bleeding tendency, blood transfusion, If yes, please specify: ____________________________________ 11. Do you smoke or chew tobacco? How much daily?_________________ 12. Do you use alcohol? How much?________________________________ 13. Have you ever sought professional care for drug abuse, O. Implants placed in your body (heart valve, hip, knee)? P. Radiation (x-ray) treatment for cancer? 14. WOMEN: Are you pregnant or planning pregnancy? Q. Clicking or popping of jaw joint, pain near ears, difficulty in Are you taking any birth control pills? opening mouth, grind or clench your teeth ? 15. Do you have any other disease, condition or problem not listed S. Any disease, drugs or transplant operation that may suppress here that you think the doctor should know about? If yes, please specify:_________________________________________ 16. Do you wish to talk with the doctor privately about anything? I understand the importance of providing a truthful health history to assist my doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor and the information I have provided here is complete and accurate. Patient/Guardian'sSignature______________________________________________ Date__________________________ PATIENT REGISTRATION FORM
Physician's Signature___________________________________________________ Date__________________________

Source: http://www.bakerfamilymedicine.com/PatientHealthHistory.pdf