PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM
Please fill in the form below, print it out, and bring it with you to our offices

MEDICAL RECORD

CHART #

DATE

DOCTOR

GENERAL INFORMATION

NAME
ADDRESS

CITY
STATE	ZIP
E-MAIL
DATE OF BIRTH	AGE
GENDER	MALE FEMALE

HOME PHONE
WORK PHONE
EMPLOYER
OCCUPATION
PRE-RETIREMENT OCCUPATION
SOCIAL SECURITY NUMBER

IN CASE OF EMERGENCY, PLEASE CONTACT:

NAME
ADDRESS

CITY
STATE

HOME PHONE
WORK NUMBER
RELATIONSHIP

GUARDIAN OR PERSON RESPONSIBLE FOR PAYMENT IF DIFFERENT FROM ABOVE:

Spouse Guardian Employer Parent

NAME
ADDRESS

CITY
STATE	ZIP

PHONE NUMBER
SOCIAL SECURITY NUMBER

MEDICARE PATIENTS - MEDICARE #

SECONDARY INSURANCE:

INSURANCE COMPANY
ADDRESS

CITY
STATE	ZIP

PHONE NUMBER
POLICY / ID NUMBER
GROUP NUMBER

NON-MEDICARE INSURANCE:

INSURANCE COMPANY
ADDRESS

CITY
STATE	ZIP
IS THIS AN HMO OR A PPO?	YES NO

RELATION TO INSURED: Self Spouse Child Other

POLICY OWNER’S NAME
PHONE NUMBER
POLICY / ID NUMBER
GROUP NUMBER OR EMPLOYEE

DID YOU BRING A REFERRAL SLIP?	YES NO

GETTING TO KNOW YOU:

How did you hear about us?

PLEASE BE SPECIFIC:

NAME AND ADDRESS OF YOUR PRIMARY CARE DOCTOR OR FAMILY DOCTOR:

NAME
ADDRESS

CITY
STATE	ZIP

PHONE NUMBER

HISTORY OF PRESENT ILLNESS

PLEASE CHECK THE ANSWERS THAT BEST DESCRIBE YOUR CONDITION.

HEIGHT WEIGHT AGE

What is your primary complaint (the reason you came here, stated in your own words)?
What are your expectations of today's visit?
When was the onset of your symptoms? Injury Sudden, without injury Gradual onset - How many? Weeks ago Months ago Years ago Duration of pain: Continuous Intermittent Chronic Acute What is the quality of pain? Improving Worsening Unchanged What kind of symptoms? Swelling Grating Giving way/buckling Locking Stiffness Where is the location of the pain? In front of leg Behind the leg On the inside of the leg On the outside of the leg Other What is the intensity of the pain? Mild Moderate Severe	Do you have difficulty? Walking Twisting Movements Sitting, then rising from chair Stairs Do you use an assistive device? Straight Cane Quad Cane Walker Crutches Brace What kind of treatment have you received? Arthritis medicine Cortisone shots Synvisc/Hyalgan injections Herbal medicines Arthroscopy Other How much difficulty or disability does this problem cause? It's a nuisance It's threatening my independence It's hindering my occupation or recreational activity It poses no difficulty Do any of the following apply? Previous injury to leg or knee Back or neck problems Problems with the hip

DESCRIBE ALL LOCATIONS WHERE YOU HAVE PAIN IN YOUR BODY
(Please use descriptive words: left, right, front, back, inner, outer, etc.)

After you have printed out this page, use a pen to place X’s where you have pain.

REVIEW OF SYSTEMS
Please check items if you have ever had:

Heart and circulation problems:
High blood pressure
Low blood pressure
Heart attack or coronary
Chest pain or angina lasting more than one minute
Troublesome, skipped or irregular heartbeats
Heart failure
Being awakened from sleep by coughing or shortness of breath
Easily fatigued
Blood clot in the lung
Phlebitis (blood clot in the leg)
Difficulty walking up two flights of stairs
Heart murmur

Lung or breathing problems:
Shortness of breath or any difficulty breathing
Any breathing problems which interfere with normal activity
Any type of chronic cough
Do you bring up anything when you cough
Asthma or wheezing
Emphysema
Bronchitis
Tuberculosis
An abnormal chest x-ray
A cold at this time

Muscle or joint problems:
Unusual muscle weakness
Arthritis or joint disease
Frequent muscle spasms
Back or neck problems
Any limited movement on your neck or jaw
Any physical disabilities
Any treatment for sciatica

Neurological problems:
Stroke
Epilepsy or seizures
Frequent headaches or migraines
Paralysis
Dizziness or fainting
An arm or a leg that becomes numb or weak frequently
Any treatment by a psychiatrist

Gastrointestinal problems:
Vomiting of blood
Stomach pain or been treated for an ulcer
Bloody or black stools
Jaundice or hepatitis
Cirrhosis or enlarged liver
Hiatal hernia
Recent vomiting
Recent diarrhea

Urinary tract or reproductive problems:
Painful burning during urination or frequent urination
Kidney or bladder infection
Prostate problems
Kidney stone
Blood in the urine
Any kidney disease
Could you be pregnant?
Start date of last menstrual period

Metabolic and blood problems:
Diabetes
Thyroid problems
Anemia
Easy bleeding/Poor blood clotting
Frequent or large nose bleeds
Sickle Cell disease
Blood transfusions

Eye, Ear, Nose, and Throat problems:
Glaucoma or other eye problems
Any serious mouth, throat, or larynx       (voice box) problem
Any nose or jaw surgery.
      When
Any false teeth, caps, bridges, loose or      chipped teeth, crowns, braces
Any contact lenses
Any difficulty hearing

Other health questions. Have you had any:
Significant weight loss in the last few       months even without dieting
Loss of appetite
Cancer or other tumors or growths
Treatment for depression
Any history of skin changing color or of       allergy after contact with jewelry or other       metal
Are you under the treatment of any       specialist
Are you feeling extremely anxious about      pending surgery

PAST MEDICAL HISTORY

ILLNESSES
Please list any other non-surgical illnesses you have had requiring hospitalization or repeated visits to your doctor and give dates:

PAST SURGICAL / ANESTHESIA HISTORY

Have you ever had ay anesthesia or surgery? If so, list surgery and approximate dates:

Have you had any problems with prior anesthetics including nausea and vomiting? YES NO

If any problems, please describe:

Have any of your blood relatives had any problems with anesthesia, including fever? YES NO

Are you allergic to local anesthesia such as xylocaine? Novocaine?

Have you had prolonged bleeding after tooth extraction or any bleeding problems? YES NO

CURRENT MEDICATIONS

Are you currently taking any medications? YES NO
If YES, please list medication names and date medication started. Please include over the counter medicines and vitamin supplements:

ALLERGIES

Please check if you are allergic to any of these drugs:

Penicillin Sulfa Codeine Iodine Novocaine

Describe your reaction to the medication:

Any other drug reactions or allergies to any other medicines? If so, please list and describe:

Do you have asthma? YES NO

SOCIAL AND FAMILY HISTORY

Married Single Widowed Divorced

Did any of your blood relatives have a heart attack or coronary? YES NO At what age?

Did any of your blood relatives have rheumatoid arthritis or osteoarthritis? YES NO

Did any of your blood relatives have problems with anesthesia, including fever? YES NO

MOTHER: Living Deceased - Cause of death Age

FATHER: Living Deceased - Cause of death Age

Some insurance companies require health care providers to ask their patients if they have a Living Will.
Do you have a Living Will? YES NO (If YES, please provide us with a copy.)

Do you live alone? YES NO

Do you have children? YES NO If yes, how many?

Exercise? Daily 2-3 x week Other

What type of exercise?

Are you on a special diet? YES NO

Describe:

Recreational drug use? YES NO

Which type When last used?

Currently smoking? YES NO packs per day, for years

Quit smoking? This year + 1 year + 5 years + 10 years

Previously smoked packs per day, for years

Drink alcohol? YES NO

Daily 1-2 x week 1-2 x month Rarely

SIGNATURES

Patient’s Signature:	Date:

Doctor’s Signature:	Date: