Patient Information Form

Date

First Name:

MI:

Last Name:

Address:

Apt #:

PO Box:

City:

State:

Zip:

Home Phone:

Cell:

Work:

Email Address:

Birthdate:

Age:

Gender

M F

Social Security #:

Employer:

Spouse's name:

Spouse's Birthdate:

Spouse Social Security #:

If you are a student or minor, who is the responsible party?

What is their address?

How did you choose our office?

Friend/Family Physician Referral Internet Phone book

Who is your primary physician?

Date last seen

If you were referred by a physician, whom?

How would you prefer we contact you?

Home Phone Cell Phone Work Phone E-Mail Text

Emergency Contact:

Phone:

Relationship:

Insurance

Please provide the receptionist with your insurance card(s).

Name of insured:

Same

Birthdate of insured:

Same

Address of insured:

Same

Phone of insured:

Same

Name of primary insurance company:

Subscriber #:

Group #:

Name of secondary insurance company:

Subscriber #:

Group #:

Name of tertiary insurance company:

Subscriber #:

Group #:

Are you seeing us for a work-related injury?

Yes No

Are you seeing us for an injury related to a car accident or injury on a person’s property?

Yes No

If yes, please explain:

I hereby assign my insurance benefits to be paid directly toaisal Nagarwala, MD / Council of Complete Cure Medical
I also authorize the physician to release any information requested by my insurance company.
I understand that the above information concerning my condition will be used for filing insurance reports.
I certify all the information to be true and complete.
I understand I am financially responsible for all charges not covered by my insurance company.

DISCLAIMER: 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:

History Form

Name:

Date:*

Height:

Weight:

Shoe Size:

Pharmacy:

Pharmacy's Location:

Describe the main problem(s) for which you would like treatment (indicate left or right):

How would you describe your pain or condition?

How would you rate your pain?

No Pain Mild Moderate Severe

1-10 Scale:

Days:

Weeks:

Months:

Years:

Others:

Describe what makes the pain/problem better:

Describe what makes the pain/problem worse:

Describe anything that has been done for treatment:

List the medications that you are taking (include OTC meds and supplements)

Add another medication.

Do you have any allergies?

Yes No known allergies

Other:

If YES, please list:

Add another allergy

List your past surgeries:

Add another surgery

Review of Systems

Past Medical History

If Other, Please Specify:

Family History

If applicable, check which family member has the following conditions:

Diabetes:

No history

Mother

Father

Sister

Brother

Other

Cancer:

No history

Mother

Father

Sister

Brother

Other

Heart disease:

No history

Mother

Father

Sister

Brother

Other

Kidney disease:

No history

Mother

Father

Sister

Brother

Other

Liver disease:

No history

Mother

Father

Sister

Brother

Other

Lung disease:

No history

Mother

Father

Sister

Brother

Other

Social History

Drug Use:

Yes No

# Caffeinated beverages/day:

Pregnant?

Yes No

If yes,number of weeks pregnant:

Occupation:

# hours on feet/day:

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