New Patient Form

Date of visit

NAME:

DOB:

Address:

City:

State:

ZIP:

Phone:

Cell:

Email address

Insurance:

Are there any changes to any of this information?

YES NO

Staff use only: For Brief Visits:

BP:

Pulse:

Wieght:

REGISTRATION FORM

Today's Date:

PCP:

PATIENT INFORMATION

Patient's Last name:

First name:

Middle:

Marital status:

Is this your legal name?

Yes No

If not, what is your legal name?

Former name:

Birth Date:

Age:

Sex:

Male Female

Address:

Social Security no.:

Home phone no.:

Cell phone no.:

Occupation:

Employer:

Employer phone no.:

Please Choose One option

Chose clinic because: Referred to clinic by:

Other Family members seen here: [Other patients]

INSURANCE INFORMATION

(Please give your insurance card to the receptionist)

Person responsible for bill:

Birth Date:

Address (if different):

Home phone no.:

Is this person a patient here?

Yes No

Is this patient covered by insurance?

Yes No

Occupation:

Employer:

Employer address:

Employer phone no.:

Please indicate primary insurance:

Subscriber's name:

Subscriber's S.S. no.:

Birth Date:

Group no.:

Policy no.:

Co-payment:

Patient's relationship to subscriber:

Other:

Add Secondary Insurance

IN CASE OF EMERGENCY

Name of local friend or relative:

Relationship to patient:

Home phone no.:

Work phone no.:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Joseph H. Roosth, MD or insurance company to release any Information required to process my claims.

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

Patient/Guardian Signature

Date

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Name

Sex:

Male Female

DOB:

Previous or referring doctor:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood Illness:

Measles

Mumps

Rubella

Chickenpox

Rheumatic Fever

Polio

Immunizations and dates

Tetanus

Hepatitis

Influenza

Pneumonia

Chickenpox

MMR (Measles, Mumps, Rubella)

If Tetanus, Date

If Hepatitis, Date:

If Influenza, Date:

If Pneumonia, Date:

If Chickepox, Date:

If MMR, Date:

List any medical problems that other doctors have diagnosed

Surgeries

Add new Surgeries

Other Hospitalizations

Add new Hospitalizations

Have you ever had a blood transfusion?

Yes No

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Add new prescribed Drugs

Allergies to Medications

Add new Allergies to Medications

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Diet

Are you dieting?

Yes No

If yes, are you on a physician prescribed medical diet?

Yes No

# of meals you eat in an average day?

Rank salt intake

HI Med Low

Rank fat intake

HI Med Low

Caffeine

None

Coffee

Tea

Cola

# of cups/cans per day?

Alcohol

Do you drink alcohol?

Yes No

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Yes No

Have you considered stopping?

Yes No

Have you ever experienced blackouts?

Yes No

Are you prone to "binge" drinking?

Yes No

Do you drive after drinking?

Yes No

Tobacco

Do you use tobacco?

Yes No

Cigarettes

Packs/day

Chew

#/day

Pipe

#/day

Cigars

#/day

#/ of years

Or year quit

Drugs

Do you currently use recreational or street drugs?

Yes No

Have you ever given yourself street drugs with a needle?

Yes No

Sex

Are you sexually active?

Yes No

If yes, are you trying for a pregnancy?

Yes No

If not trying for a pregnancy, list contraceptive or barrier method used:

Any discomfort with Intercourse?

Yes No

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness Include intravenous drug use and unprotected sexual Intercaurse. Would you like to speak with your provider about your risk of this Illness?

Yes No

Personal Safety

Do you live alone?

Yes No

Do you have frequent falls?

Yes No

Do you have vision or hearing loss?

Yes No

Do you have an Advance Directive and/or Living Will?

Yes No

Would you like Information on the preparation of these?

Yes No

Physical and/or mental abuse have also become major public health Issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this Issue with your provider?

Yes No

FAMILY HEALTH HISTORY

Father

Age

SIGNIFICANT HEALTH PROBLEMS

Mother

Age

SIGNIFICANT HEALTH PROBLEMS

Sibling

M F

Age

SIGNIFICANT HEALTH PROBLEMS

Add new Sibling

Children

M F

Age

SIGNIFICANT HEALTH PROBLEMS

Add new Children

Grandmother

Maternal

Age

SIGNIFICANT HEALTH PROBLEMS

Grandfather

Maternal

Age

SIGNIFICANT HEALTH PROBLEMS

Grandmother

Paternal

Age

SIGNIFICANT HEALTH PROBLEMS

Grandfather

Paternal

Age

SIGNIFICANT HEALTH PROBLEMS

MENTAL HEALTH

Is stress a major problem for you?

Yes No

Do you feel depressed?

Yes No

Do you panic when stressed?

Yes No

Do you have problems with eating or your appetite?

Yes No

Do you cry frequently?

Yes No

Have you ever attempted suicide?

Yes No

Have you ever seriously thought about hurting yourself?

Yes No

Do you have trouble sleeping?

Yes No

Have you ever been to a counselor?

Yes No

WOMEN ONLY

If women

MEN ONLY

If Men

Department of State Health Services Notice of Privacy Practices

ACKNOWLEDGEMENT OF REVIEW

Date:

I have reviewed the Department of State Health Services Notice of Privacy Practices (version effective September 1, 2017), which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this notice if requested.

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

Patient Name

Patient Signature

If completed by a patient's personal representative, please print and sign your name in the space below.

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

Personal Representative

Personal Representative Signature

For Office Use only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communication barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please be specific):

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

Employee Signature

Date

Your information will be encrypted.

New Patient Form

REGISTRATION FORM

IN CASE OF EMERGENCY

HEALTH HISTORY QUESTIONNAIRE

PERSONAL HEALTH HISTORY

HEALTH HABITS AND PERSONAL SAFETY

FAMILY HEALTH HISTORY

MENTAL HEALTH

WOMEN ONLY

MEN ONLY

OTHER PROBLEMS

Department of State Health Services Notice of Privacy Practices

ACKNOWLEDGEMENT OF REVIEW