New Patient Packet

Patient Information Form

First Name:

Middle Name:

Last Name:

Phone (Home #):

Phone (Cell #):

Email:

Patient's Social Security Number:

Date of Birth

Gender:

Male Female Other

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Unknown Other Declined to state

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Other Declined to state

Preferred Language:

English Other Declined to state

Address:

Apt. #

State:

Zip:

City:

Emergency Contact: Name:

Phone:

Relationship:

Referring Provider/Doctor:

Specialty:

Primary Care Physician

Address:

Suite.#

City:

State:

Zip :

Telephone Number:

Fax Number:

Primary Insurance Company Name:

ID#

Group#

Subscriber (Insured) Name:

Date of Birth:

Subscriber's relationship to patient:

Self Spouse Father Mother SSDP Other

Secondary Insurance Company Name:

ID#

Group#

Subscriber (Insured) Name:

Date of Birth:

Subscriber's relationship to patient:

Self Spouse Father Mother SSDP Other

If Medicare is Secondary Insurance, one must of the following be selected:

Checkbox list

Working Aged Beneficiary or Spouse with Employer Group Health Plan

End-Stage renal Disease Beneficiary in the Mandated Coordination Period

No-fault Insurance including Auto is Primary

Worker's Compensation

Public Health Service or Other Federal Agency

Black Lung

Veteran's Administration

Disabled Beneficiary Under Age 65 with Large Group Health Plan

Other Liability Insurance is Primary

Please list any persons below can obtain any/all medical information on myself/patient and whom we can communicate with about your medical information .This is in accordance with the Knight Neurology LLC notice of privacy practices policy. (This is optional but even immediate family members such as a spouse must be specifically listed to obtain any medical information about you.)

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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 Signature

Date

New Patient Health Information Intake Form

Patient Name:

Date of Birth:

Reason for your visit:

Any Specific Question that you have today:

Referring Provider/Doctor:

Primary Care Physician

Address:

Telephone Number:

Fax Number:

Any other doctors (and their addresses) to whom reports should be sent:

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Preferred Pharmacy Name (leave blank if unknown):

Address:

Telephone Number:

Fax Number:

Patient Name

Date of Birth:

Medications:

Please list current medications including vitamins and other non-prescription medications:

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Allergies:

Pleaselist all medicationsthat have caused you to have an allergic reaction.

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Patient Name:

Date of Birth:

Past Medical History:

Do you have or have you had any of the following:

High Blood Pressure

Yes No

Diabetes

Yes No

High Cholesterol

Yes No

History of Heart Attack

Yes No

History of Stroke

Yes No

Cancer

Yes No

Congestive Heart Failure

Yes No

Please specify any other medical condition or past surgeries:

Family History:

Please include all primary blood relatives(parents, siblings, children) even if they are healthy.

If Living

If Deceased

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Social History:

What hand do you use for writing or sports(Select one):

right left both

Tobacco Usage:

Never used tobacco

Currently use tobacco

How many packs/units per day?

Formerly used tobacco

How many packs/units per day?

What year did you quit?

For how many years?

Type (Select one if applies):

Cigarettes Pipe Cigar Chewing tobacco Other

Alcohol Usage:

Never Few times per year Few times per month 1-2 times per week 1 per day 2 per day More than 2/day History of alcohol dependence but no current use

Illicit Drug Usage:

No history of illicit drug use No current drug use but past history of illicit drug use Current use of illicit drug

Type (Select one if applies):

Marijuana/Cannabis Crack/Cocaine Meth Heroin LSD Ecstasy Other

What is Your highest level of Education?

High school College Graduate school

Work Status:

Occupation:

Retired Unemployed

Marital Status:

Married Single Divorced widow Separated Long term relationship Other Declined

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