1. PATIENT INFORMATION
Race:
Hispanic origin
If Hispanic please select ethnicity:
Have You Ever Used Another Name?
If “Yes”:
Gender
Mother's Maiden Last Name:
Preferred Language:
Marital Status:
If The Child Is Under 18 and Receiving Vaccines Please Complete The Following:
2. INSURANCE INFORMATION</b> (Please Give Your Insurance Card To the Receptionist)
Is This Patient Covered By Insurance?
Please Indicate Primary Insurance: (if any)
Co-Payment:$
Patient's Relationship To Subscriber:
3. IN CASE OF EMERGENCY
4. MEDICAL POWER OF ATTORNEY
5. HOW DID YOU HEAR ABOUT US?
Advertising:
Social Media:
Other:
FOR OFFICE USE ONLY
Please Check and Identify Relationship if any Relative (parent, sibling, grandparent, child, etc.) has had any of the following conditions:
Please Check any of the following illnesses that you have experienced:
Other Serious Illness:
Please list the dates and results (if known) of the following:
Any History of Dysplasia?
Any Treatment for Dysplasia?
Please list any medications, prescription and over-the-counter, that you are currently taking:
Have you ever been hospitalized?
If so, when, where, and for what reason?
Do you drink alcohol or use any drugs??
If so, what do you use, how much, and how frequently?
Do you smoke cigarettes?
If so, how many cigarettes do you smoke per day?
Are you interested in quitting Cigarettes?
Please list any vitamins or supplements you are currently taking:
Pain Screening:
Are you experiencing any type of pain?
If “yes,” in what areas:___
Please mark an X as to what your level of pain you are experiencing today:
Nutrition Screening:
PLEASE CHECK YES OR NO
1. Have you lost or gained at least 10 pounds within the last six months?
Yes
No
2.Have you noticed a change in the distribution of fat in your body within the last six months?
3.Have you been informed that your cholesterol levels have increased from the time of your last medical appointment?
4.Do you need information regarding nutritional supplements and how to access them?
