Pre Register - Cnymedical

Last Name *

First Name *

Middle Name

Date of Birth *

Height

Weight

Patient is a child Whom they live with ?

Is the home smoke free?

Gender

Marital status

Social Security Number

Address *

City

Zip

State

Phone (Home)

Phone (Work)

Phone (Cell) *

Email Id *

Race

Hispanic

Language

Reason for visit

Spouse Name (If Married) Or Parent Name (If Child)

Spouse/Parent Date of Birth

Spouse/Parent Social Security Number

Primary MD

Address

Phone Number

Referring MD

Address

Phone Number

Allergies

Not Known

Sulfa

Penicillin

Codeine

Latex/tape

IV contrast/Iodine

Other

Past or Current Medical History

Asthma/COPD

Seizure/Convulsions

Mental illness

Heart problems

High blood pressure

Bleeding tendency

High cholesterol

Diabetes

Stroke/heart attack

Thyroid disorders

Acid reflux/GERD

Radiation to neck

Headaches

Arthritis

Hearing Difficulty

Cancer

Other

Past Surgical History

None

Tubes

Sinus

Adenoids or Tonsils

Thyroid

Mastoids

Cardiac surgery

Gallbladder

Tracheostomy

Appendix

Heart

Varicose Veins

Breast-Lumpectomy/Mastectomy

Other

Pharmacy

Name

Local

Mail Order

Current Medications (Name/Dose, Name/Dose, ...)

Past Family Medical History

	Father	Mother	Brother(s)	Sister(s)
Thyroid cancer	Thyroid cancer Father	Thyroid cancer Mother	Thyroid cancer Brother(s)	Thyroid cancer Sister(s)
Head/neck cancer	Head/neck cancer Father	Head/neck cancer Mother	Head/neck cancer Brother(s)	Head/neck cancer Sister(s)
Cancer, Other:
Asthma/Allergies	Asthma/Allergies Father	Asthma/Allergies Mother	Asthma/Allergies Brother(s)	Asthma/Allergies Sister(s)
Hearing loss	Hearing loss Father	Hearing loss Mother	Hearing loss Brother(s)	Hearing loss Sister(s)
Diabetes	Diabetes Father	Diabetes Mother	Diabetes Brother(s)	Diabetes Sister(s)
Heart Disease	Heart Disease Father	Heart Disease Mother	Heart Disease Brother(s)	Heart Disease Sister(s)
Bleeding Disorders	Bleeding Disorders Father	Bleeding Disorders Mother	Bleeding Disorders Brother(s)	Bleeding Disorders Sister(s)
High Blood Pressure	High Blood Pressure Father	High Blood Pressure Mother	High Blood Pressure Brother(s)	High Blood Pressure Sister(s)
Stroke, Other:

Social History Recreational Drugs

Social History Alcohol

Social History Tobacco

Tobacco Pack per day

Name of Insurance Company

Who holds insurance for the patient ?

Name of Subscriber

Date of Birth

Social Security Number

City

State

Zip

Address

Employer

Phone

Address

Policy or ID Number

Group Number

Name of Insurance Company

Who holds insurance for the patient ?

Name of Subscriber

Date Of Birth

Social Security Number

City

State

Zip

Address

Employer

Phone

Address

Policy or ID Number

Group Number

Pre Registration

Secure Form :: Pre Registration

Allergies

Past or Current Medical History

Past Surgical History

Pharmacy

Past Family Medical History

Constitutional Symptoms

Skin

Eyes

Ears/Nose/Mouth/Throat

Cardiovascular

Pulmonary

Gastrointestinal

Genitourinary

Musculoskeletal

Neurological

Endocrine

Psychiatric

Hematologic

About Us

Sleep Lab

Patient Resources

Pre Registration

Secure Form :: Pre Registration

PATIENT INFORMATION

MEDICAL INFORMATION

Allergies

Past or Current Medical History

Past Surgical History

Pharmacy

Past Family Medical History

SOCIAL INFORMATION

Social History Occupation

REVIEW OF SYSTEM

Constitutional Symptoms

Skin

Eyes

Ears/Nose/Mouth/Throat

Cardiovascular

Pulmonary

Gastrointestinal

Genitourinary

Musculoskeletal

Neurological

Endocrine

Psychiatric

Hematologic

INSURANCE INFORMATION (PRIMARY)

INSURANCE INFORMATION (SECONDARY)

About Us

Sleep Lab

Patient Resources