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Secure Form :: Pre Registration
* Required Fields
PATIENT INFORMATION
Last Name
*
First Name
*
Middle Name
Date of Birth
*
Height
Weight
Patient is a child Whom they live with ?
Is the home smoke free?
Yes
No
Gender
male
female
other
Marital status
single
Marital
Social Security Number
Address
*
City
Zip
State
State
Alaska
Arizona
California
Montana
Hawaii
Phone (Home)
Phone (Work)
Phone (Cell)
*
Email Id
*
Race
Hispanic
Yes
No
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
MEDICAL INFORMATION
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 INFORMATION
Social History Recreational Drugs
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Social History Alcohol
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Social History Tobacco
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Tobacco Pack per day
Social History Occupation
Patient Occupation
Veteran
REVIEW OF SYSTEM
Constitutional Symptoms
Good general health lately
Recent weight change
Fever
Fatigue
Headaches
Skin
None
Itching
Rash
Lesion
Lump
Skin Cancer
Bump
Laceration
Other
Eyes
Wear glasses
Wear contact lenses
Blurred or double vision
Glaucoma
Ears/Nose/Mouth/Throat
Ringing in ears
Difficulty Hearing
Hearing test within last 2 yrs
Chronic sinus problems
Nose bleeds
Earaches or drainage
Bleeding gums
Sore throat
Hoarseness
Difficulty swallowing
Frequent ear infections
Loss of taste
Cardiovascular
None
Chest pain
Palpitations/Irregular heart beat
Heart Attack
Pacemaker
Other
Pulmonary
None
Asthma/wheezing
Shortness of breath
Breathing difficulty
Sleep apnea/disturbance
Other
Gastrointestinal
None
Abdominal pain
Diarrhea
Difficulty swallowing
Heartburn
Nausea
Loss of appetite
Vomitinge
Other
Genitourinary
None
Kidney stones
Rash/itching
Other
Musculoskeletal
None
Osteoporosis
Arthritis
Back Pain
Other
Neurological
Weakness
Seizures
Dizzness
Unsteady Gait
Fainting
Other
Endocrine
Heat/cold intolerance
Other
Psychiatric
None
Depression
Abnormal Sleep
Anxiety
Memory loss/confusion
Other
Hematologic
None
Easy bruising
Past blood transfusions
Exposure to HIV / AIDS
Is this due to an injury ?
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Workers compensation claim
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Date of Injury
INSURANCE INFORMATION (PRIMARY)
Name of Insurance Company
Who holds insurance for the patient ?
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Name of Subscriber
Date of Birth
Social Security Number
City
State
State
Alaska
Arizona
California
Montana
Hawaii
Zip
Address
Employer
Phone
Address
Policy or ID Number
Group Number
INSURANCE INFORMATION (SECONDARY)
Name of Insurance Company
Who holds insurance for the patient ?
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value2
Name of Subscriber
Date Of Birth
Social Security Number
City
State
State
Alaska
Arizona
California
Montana
Hawaii
Zip
Address
Employer
Phone
Address
Policy or ID Number
Group Number
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