Registration Form
Patient Information
Patient's Legal Name:
Former Name:
Nickname:
Birth Sex:
Male
Female
Social Security Number:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
Current Address:
City:
State:
Zip Code:
Email Address:
Emergency Contact
Name:
Relationship:
Phone:
Patient Demographics
Sexual Orientation:
Straight
Lesbian or Gay
Bisexual
Something Else
Don't Know
Choose not to disclose
Gender Identity:
Male
Female
Transgender Male
Transgender Female
Other
Choose not to disclose
Marital Status:
Single
Married
Divorced
Widowed
Annulled
Race:
White
Black or African American
American Indian or Alaska Native
Black or African American
Native Hawaiian
Other Pacific Islander
More than one race
Unreported/Refused to Report Race
Ethnicity:
Not Hispanic or Latino
Hispanic or Latino
Declined to Specify
Unknown
Other
Preferred Language:
English
Lao
Vietnamese
Other (please specify below)
Other:
Homeless Status:
Not Homeless
Homeless
Other (please specify below)
Other:
Agricultural/Fishing Worker Status:
Not a Farm Worker
Migrant Worker
Seasonal Worker
Language Barrier:
Yes
No
Public Housing:
No
Other
Public Housing
Tenant Based Voucher
Veteran Status:
Yes
No
Patient Employment
Employer Name:
Employer Phone:
Yearly Household Income:
Family Size:
Guarantor Information (Information of person financially responsible for patient):
Check if same as above patient. If not please fill out the following:
Same
Name:
Relationship:
Date of Birth:
SSN:
Phone:
Current Address:
City:
State:
Zip Code:
Email Address:
Guarantor Employer Name:
Employer Phone:
Insurance Information
Primary Insurance Plan Name:
Policy ID:
Group #:
Subscriber Name:
Subscriber Date of Birth:
Subscriber SSN:
Subscriber Relationship to Insured:
Secondary Insurance Plan Name (If applicable):
Policy ID:
Group #:
Subscriber Name:
Subscriber Date of Birth:
Subscriber SSN:
Subscriber Relationship to Insured:
Preferred Pharmacy
Pharmacy Name:
Pharmacy Phone Number:
Pharmacy Location:
Patient/Legal Guardian Name:
Patient/Legal Guardian Signature:
Reset Signature
Created 5/8/2018; Revised 1/28/2020; Revised Electronically 4/28/2020
NB-119
NEW PATIENT HEALTH HISTORY QUESTIONNAIRE
All information contained in this questionnaire is strictly confidential and will become a part of your medical record.
Name :
Sex:
Male
Female
Date of Birth:
Age:
Is it related to an accident?
No
Yes ,it is
Work injury
Motor vehicle accident
Other
ALLERGIES: Do you have any drug/food allergies or intolerances?
No
Yes; Please describe below
MEDICATIONS:
Please list all medications that you are taking, including non-prescription medications (Advil, Aleve, Motrin, Tylenol, etc.), vitamins, and supplements.
Name of drug (put "none" if you are not on any medications)
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
Name of drug
Dose (strength and times taken per day)
How long have you taken this?
IMMUNIZATIONS:
Please enter the year of any vaccinations you have had.
Hepatitis A
Flu Shot
Meningitis
MMR
Hepatitis B
Pneumonia
Shingles
Tetanus
HPV
Chicken Pox (shot or illness)
Other
Have you had a colonoscopy/sigmoidoscopy?
No
Yes
; when and where was it performed?
WOMEN ONLY:
Number of pregnancies:
Number of children:
Number of miscarriages:
Number of abortion:
Last pap smear (date and location):
Have you had an abnormal pap smear?
Yes
No
Last period:
Age at first period:
Age at menopause:
Last bone density scan (date and location):
Last mammogram (date and location):
MEN ONLY:
Last prostate exam (date and location):
Last PSA (prostate blood test) (date and location):
HOSPITALIZATIONS/SURGERIES:
Please list the hospitalizations and/or surgeries and the reason:
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
Year
Reason for surgery/hospitalization
Hospital
PAST MEDICAL HISTORY:
Do you now or have you had any of the following?
Alcohol/Drug abuse
Allergy (hay fever)
Anemia
Arthritis
Asthma
Blood clot
Bruising
Cancer (Type)
Cataracts
Depression/ Anxiety
Diabetes
Difficulty breathing
Dizziness
Eczema
Emphysema
Eye pain
Fainting or loss of consciousness
Fatigue
Fractures (broken bones)
Gallbladder disease
Glaucoma
Gout
Hair loss
Hearing loss
Heartburn/Reflux
Heart attack (when )
Heart problems
Hepatitis
High blood pressure (hypertension)
High cholesterol
HIV/AIDS
Hyperthyroidism
Hypothyroidism
Jaw pain/TMJ
Kidney disease/ problems
Leg pain/swelling
Liver disease/ problems
Memory loss
Migraine headaches
Muscle weakness
Nausea
Night sweats/hot flashes
Osteoporosis
Pneumonia
Prostate disease/ problems
Psoriasis
Seizure/Epilepsy
Skin conditions/rashes
Sleep apnea
Stomach ulcer
Stroke (when )
Urination increase/decrease
Vision problems
Vomiting, persistent
Other
MEDICAL PROVIDERS: Please list the names of other healthcare providers and the problems for which they are treating you.
FAMILY HISTORY:
Father:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
Mother:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
Brothers:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
Sisters:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
Daughters:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
Sons:
Living?
Yes
No
Age (current or at death)
Current medical problems or cause of death
SOCIAL HISTORY:
Do you exercise regularly?
No
Yes;
how often?
Do you drink alcohol?
No
Yes
If yes, how many drinks per day?
How many per week?
Do you currently or have you ever smoked?
No
Yes
If yes, how much?
For how long?
Do you currently or have you ever used smokeless tobacco?
No
Yes
If yes, how much?
For how long?
Have you used drugs other than those required for medical reasons?
No
Yes
How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?
Are you currently or have you ever been sexually active?
No
Yes
Are your sexual partners:
Male
Female
Both
Thank you for taking the time to complete this form.
Signature of Patient or Legal Representative
Date
Created 5/6/2019; Revised Electronically 4/28/2020
NB-148