New Patient Packet (English)

Patient Registration Form

All fields must be completed prior to screening visit for study participation.

Patient Information

Last Name

First

Middle

Date of Birth

Social Security Number

Sex assigned at birth

Male Female Other

If other, specify

Current Gender Identity

Male Female Other

If other, specify

Marital status

Single Married Widowed Separated Divorced

Primary Language

English Spanish Other

If other, specify

Can you read/understand English without interpretation?

Yes No

Can you read/understand Spanish without interpretation?

Yes No

Home Address

Apt/Unit

City

State

ZIP

Phone numbers

Home

Cell

Work

Other

Which is your preferred contact number?

Home Cell Work Other

Emergency Contacts

Name

Relationship

Phone

Name

Relationship

Phone

Required information

Ethnicity

Hispanic or Latino or Spanish origin Not Hispanic or Latino or Spanish origin

Race

American Indian-Alaska native Asian Black/African American White/Caucasian Native Hawaiian/Pacific Islander Other

If other, specify

Please answer the following questions to the best of your ability.

Approximate weight in pounds

5 years ago

6 months ago

Today

Do you exercise regularly (3x per week for 20 minutes or more)?

No Yes

Approximate Height in feet and inches

Personal Health Information

Total Number of persons in your household (including yourself)?

Sexual orientation

Heterosexual Lesbian Gay Bisexual Pansexual Prefer not to disclose Other

If other, specify

Do you work with the public?

No Yes

Occupation

Substance Intake

1. Do you smoke cigarettes?

Yes Never Quit smoking

on (approx. date)

How many packs do you or did you smoke daily?

There are 20 cigarettes in each pack.

For how long? (yrs.)

2. Do you vape?

No Yes, daily Almost daily Up to 3x a week Less than 1x a week

3. Do you use marijuana/THC?

No Yes, daily Almost daily Up to 3x a week Less than 1x a week

4. Do you drink alcoholic beverages?

No Yes, daily Almost daily Up to 3x a week Less than 1x a week

5. Do you drink caffeinated beverages/energy drinks?

No Yes, daily Almost daily Up to 3x a week Less than 1x a week

6. Do use recreational drugs?

No Yes, daily Almost daily Up to 3x a week Less than 1x a week

If you do, what kind

7. Is there any other substance use information that you feel is important for the study doctor to know about you?

No Yes

If yes, specify

Woman’s Health History (if applicable)

Age period started?

Average duration

(# of days per cycle)

Date of last period

Do you have abnormal menstrual bleeding?

No Yes

If yes, describe

Date of last Pap smear

Date of last mammogram

# of pregnancies

# of Deliveries

# of Abortions/Miscarriage

Are you currently a female of child bearing potential?

Yes No

If no, complete below.
Reason

Post-Menopausal

Date

Hysterectomy (uterus removed)

Date

Tubal ligation (tubes tied)

Date

Other

If other, specify

Date

Contraceptive Information (applicable to all genders)

What is your current method of contraception (pregnancy prevention)? Males and Females need to complete this section.

Are you diagnosed with any medical disabilities?

No Yes

Please list below

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Allergies or Medication Reactions

Have you ever had any Allergies or Medication reactions?

No Yes

Please list below

Add new row

Current Medications (included Vitamins and Herbal Medicines)

Check here if you are not currently taking any medications.

Complete below.

Add new row

Vaccination History

Check here if you have never had any vaccinations.

Name of Vaccine

1. Measles

Yes No Unsure

Date

2. Mumps

Yes No Unsure

Date

3. Polio

Yes No Unsure

Date

4. Rubella (German Measles)

Yes No Unsure

Date

5. Hepatitis

Yes No Unsure

Date

6. Pneumonia Vaccine: PCV13 (Prevnar 13)

Yes No Unsure

Date

7. Pneumonia Vaccine: PCV15 (Vaxneuvance)

Yes No Unsure

Date

8. Pneumonia Vaccine: PCV20 (Prevnar 20)

Yes No Unsure

Date

9. Pneumonia Vaccine: PCV13 (Pneumovax23) PPSV23

Yes No Unsure

Date

10. Tetanus

Yes No Unsure

Date

11. Flu

Yes No Unsure

Date

12. Chicken pox

Yes No Unsure

Date

13. COVID: 1st dose

Yes No Unsure

Specify

Date

14. COVID: 2nd dose

Yes No Unsure

Specify

Date

15. COVID: 3rd dose

Yes No Unsure

Specify

Date

16. COVID: 4th dose

Yes No Unsure

Specify

Date

Date of last TB test

Result

Positive Negative

Surgery History

Check here if you have no history of surgeries.

Add new row

Hospitalization History

Check here if you have never been hospitalized.

Add new row