New Patient Registration Form

Name:

Patient Account #:

Sex:

Home Phone:

Work Phone:

Cell Phone:

Address:

City:

State:

Zip:

Date of Birth:

Age:

Marital Status:

Preferred Language:

Spouse's Name:

Social Security Number:

Race/Ethnicity (optional):

Email:

Occupation:

Employer:

Emergency Contact (not living with you):

Phone:

Relationship to Patient:

Insured party (if different than above)

Name:

Sex:

Home Phone:

Work Phone:

Cell Phone:

Address:

State:

City:

Zip:

Social Security Number:

Driver's License Number:

E-mail: (Optional)

Occupation:

Employer:

Primary Care MD:

Primary Care MD Phone:

Referral Source:

Insurance Company:

May we leave messages with private health info on your answering machine at home?

Yes No

May we leave messages with private health info on your answering machine at work?

Yes No

May we leave messages with private health info on your answering cell voicemail?

Yes No

Please list with whom we can discuss your private health information:

Add another authorized person

If you selected Cancer, site?

Please list all surgical procedures and approximate years:

Add another surgical procedure

Please list any other hospitalizations or major injuries:

Add another hospitalization/major injury

FAMILY HISTORY

Father

Alive?

Yes No

Age (now or at death)

Good Health?

Yes No

Major Illnesses:

Cause of Death:

Mother

Alive?

Yes No

Age (now or at death)

Good Health?

Yes No

Major Illnesses:

Cause of Death:

Add another sibling/child

Other Family conditions (please list):

Do you smoke tobacco?

Yes No

Have you ever?

Yes No

If yes, how much?

If quit, what year?

Do you drink alcohol?

Yes No

How much or how often?

How many caffeinated drinks do you take a day?

Do you have any on-the-job chemical, fume or loud noise exposures?

Yes No

If yes, what type(s)?

Please select if you currently suffer from the following:

Pulmonary

Positive TB Skin Test

Persistent Cough

Shortness of Breath

Breathless during Excercise

Breathless when laying flat

Phlegm in Chest

Wheezing

Coughing up Blood

Cardiovascular

Chest Pain

Rapid Heartbeat

Skipped Beats/Palpitations

Swelling in Legs

Blood Clots in Legs

Leg Pain while Walking

Pain with Urination

Frequent Urination

Urination at Night

Hard to Start Urine Stream

Blood or Pus in Urine

Leakage of Urine

Skin

Easy Bruising

Easy Bleeding

Change in Moles

Non-Healing Sores

Rash

Men's Health

Breast Lump

Penis Discharge

Sore on Penis

Lump on Testicles

Difficulty with Erection

Women's Health

Breast Lump or change

Nipple Discharge

Change in Menstruation

Pelvic Pain

Abnormal PAP Smear

Vaginal Discharge

MusculoSkeletal

Limb Pain

Joint Pain

Weakness

Numbness

Swelling

Back Problems

Leg Cramps at Night

What is the reason for your visit?

How long have you had these symptoms?

What treatment have you been given? Any tests administered?

What medication have you been given for this condition?

Your Pharmacy Name

Your Pharmacy Location

Medicine and Allergy List

Please list medications to which you are allergic or sensitive (Write "None", if appropriate):

Add another medication

List the medicine that you are currently taking. Please remember to list presciption, over-the-counter, and herbal medicines. If regular doses of pain or anti-inflammatory medicines are used, list these. Also list topical medicines including drops, creams.

Add another medicine

I ACKNOWLEDGE AND AGREE TO THE FOLLOWING:

I have reviewed a copy of the Notice of Privacy Practices of ENT Associates Medical Group. This Notice describes how ENT Associates may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

ENT Associates reserves the right to charge for broken appointments without 24 hours advance notice.
I hereby assign to ENT Associates all benefits provided by my insurance policy, not to exceed the charges for services rendered.
I am financially responsible for healthcare charges not covered by insurance.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

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