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Location Name : 8150 Southwest Freeway, Houston TX 77074
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PATIENT REGISTRATION FORM

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


CONFIDENTIAL MEDICAL HISTORY FORM

Please Check and Identify Relationship if any Relative (parent, sibling, grandparent, child, etc.) has had any of the following conditions:

Condition Family History Relationship Condition Family History Relationship
High Blood Pressure Kidney Disease
Stroke Bleeding Tendencies
Cancer Seizures
Emphysema Heart Disease
Ulcers Sugar Diabetes
Sickle Cell Asthma
Tuberculosis Colitis
Anemia Gout
Mental Health Conditions Substance Abuse
Other Serious Illness (Please list): Other Serious Illness (Please List)

Please Check any of the following illnesses that you have experienced:

Other Serious Illness:


CONFIDENTIAL MEDICAL HISTORY FORM

Please list the dates and results (if known) of the following:

Last TB Skin Test: Last Hepatitis A Vaccine:
Last X-ray: Last Hepatitis B Vaccine
Last EKG: Last Mammogram:
Last Blood Count: Last Colonoscopy:
Last Exam by Doctor: Last PSA/Rectal Exam:
Last Tetanus Vaccine: Last Pap Smear:
Last Pneumonia Vaccine: Last Influenza Vaccine:

Any History of Dysplasia?

Any Treatment for Dysplasia?

Please Check any of the following illnesses that you have experienced:

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?

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?