New Patient Forms

Patient Registration Form

Date

PATIENT REGISTRATION INFORMATION:

In order to meet criteria established by the Federal Government through the Electronic Health Record (EHR) Incentive Program, Elgreat Healthcare Center must obtain complete demographic data on every patient including preferred language, race, and ethnicity. If you prefer not to answer these questions you may choose to decline. Thank you for your cooperation.

Name: Last

First

Middle

Suffix

Date of Birth

Primary Language

Birth Sex

Male Female Unknown Declined

Sexual Orientation

Straight or Heterosexual Lesbian, Gay or Homosexual Bisexual Do Not Know Choose Not to Disclose Something Else

Please describe

Gender Identity

Male Female Female-to-Male (FTM)/Transgender Male/Trans Man Male-to-Female (MTF)/Transgender Female/Trans Woman Genderqueer, neither exclusively male nor female Choose not to disclose Additional Gender Category or other

Please specify

Race

American Indian/Alaska Native

Black/African American

Native Hawaiian/Pacific Islander

Asian

White

Declined

Other

If other, please specify.

Ethnicity

Hispanic or Latino Non-Hispanic or Latino Declined

Marital Status

Driver's License #

State

Address

City

State

Zip

Home Phone

Mobile

Work Phone

Pharmacy

Phone #

Pharmacy Address

Employer

Occupation

Employer Address

INSURANCE INFO: Do you request that we file your insurance and authorize your company to pay us benefits directly?

Yes No

Carrier

Policy Holder

Date of Birth

Relationship

Policy #

Group #

Effective Date

Emergency Contact

Referring Physician

Patient History

Today’s Date

Patient Name

Date of Birth

Phone Number: Home

Work

Mobile

Best number to reach you?

Cancer: Type

Other

Orthopedic

Other

Date of Last Colonoscopy

Date of Last DEXA

Date of Last Eye Exam

MEDICATIONS: (Please list current MEDICATIONS with dosing (Including nonprescription meds, vitamins, and supplements)

ALLERGIES: (Please list any ALLERGIES to medications, latex, or any other substances)

FAMILY HISTORY: (Check illnesses which have occurred in any of your BLOOD RELATIVES)

Allergy

Cancer

Heart disease

Kidney disease

Tuberculosis

Bleeding tendency

Diabetes

High Blood Pressure

Nervous Illness

Other

REPRODUCTIVE HISTORY: (if applicable)

Onset of last menstrual cycle

Periods are

Regular Irregular Other

If other, specify.

Number of pregnancies

Number of miscarriages

Current contraceptive

Date of Last Mammogram

Date of Last Pap Smear

SOCIAL HISTORY: (if applicable)

Occupation

How long?

Marital Status

Married Divorced Widowed Single

Do you Exercise?

Yes No

TIMES #

Do you use: Tobacco

Yes No

#/Day

years of use

Do you use: Alcohol

Yes No

#/Day

years of use

Do you use: Caffeine

Yes No

#/Day

years of use

Do you use: Illegal Drugs

Yes No

#/Day

years of use

Education Level

Where and when have you lived or traveled outside of the U.S. or Canada

Mother

Living Deceased

Father

Living Deceased

Brothers: #Living

#Deceased

Sisters: #Living

#Deceased

Do you have any children?

Yes No

If YES, please list date of birth, age, and gender

IMMUNIZATIONS: Check the disease against which you have been immunized. Please list the most current immunization date and location.

Smallpox

Pneumonia

Tetanus

Pneumovax

Typhoid

Prevnar

Polio

Other (specify)

Influenza

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