FOR OUR NEW PATIENTS: Registration Forms

Registration Forms

Dr. Neskovic's Family Practice Medical Office Adult Registration Form Patient Name: Last Name First Name Middle Name Address: City: State: Zip: Home Phone: Mobile Phone: Social Security: Sex: M F Birthdate: Age: Birthplace: Marital Status: Spouse/Partner’s Name: Your occupation: Employer: Work Phone: Work Address: City: Zip: Person to Contact in case of emergency: Relation: Address: Phone No.: City: State: Zip: Name of Insurance: Guarantor’s name: Relation to patient: Guarantor’s birthdate: Social Security: Certificate/ID #: Group/Policy #: Guarantor’s employer: Address of employer: City: State: Zip: How did you hear about this practice? My preferred method of communication (eg. Test results) is through: (circle one or more) Telephone Regular mail E-mail In person I authorize the release of any medical information necessary for care or treatment or to process an insurance claim. I also hereby authorize my insurance benefits, if any, to be paid directly to Spasoje M Neskovic, MD. I acknowledge receipt of the Notice of Privacy Practices for Dr Neskovic's Family Practice Medical Office and that I may obtain a paper copy of this Notice of Privacy Practices upon request. Signature Date Dr Neskovic's Family Practice Adult Health History PATIENT NAME_______________________________________________________________ DATE________________________ This history form provides us with information to help us meet all your healthcare needs. This is a confidential part of your medical record and will not be shared with anyone else without your permission unless there is an immediate risk to yourself or others. Please list all medicines you are currently taking (include nonprescription drugs or vitamins): __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Please list all allergies (foods, drugs, environment): Please list all serious illnesses, operations, and other hospitalizations you have experienced and indicate year these occurred: Have you ever used any tobacco products? No Yes _______________________________________________ If former smoker, date quit_________________________ Do you ever drink any alcohol? No Yes _______________________________________________ Do you ever drink any caffeine products? No Yes Have you ever used any recreational drugs? No Yes Exercise/recreation_______________________________ ______________________________________________ Who lives with you? _______________________________________________ _______________________________________________ PAST MEDICAL HISTORY Circle if you have ever had any of the following: Chicken Pox Asthma Hives or Eczema Nasal allergies or hay fever High blood pressure High cholesterol Heart disease or heart attack Diabetes Migraine Headaches Seizures Stroke or TIA Cancer Blood transfusions Positive TB skin test Hepatitis Kidney disease Thyroid disease Anemia Blood clots Depression Anxiety Eating disorder Sexually transmitted infection AIDS or HIV infection Date of Last Tetanus shot ________________ Women only: Date of last period ___________ Last Pap smear ___________ Last Mammogram ___________ Type of birth control used ____________________________ # Pregnancies _____________ # Full term births _____________ # Preterm births _____________ FAMILY HISTORY Circle if any blood relative has had any of the following: Cancer Diabetes Heart disease High blood pressure High cholesterol Stroke Asthma Thyroid disease Kidney disease Drug or alcohol problem Depression REVIEW OF SYSTEMS Circle if you are currently having any problems with the following: Abnormal fatigue Weight problem Vision problems Problems with ears, nose or throat Lung or breathing problems Heart problems Stomach or digestive problems Urination problems Joint or muscle problems Neurologic or nerve problems Skin problems Allergy problems Bleeding problems Sleep problems Anxiety or depression Sexual problems Domestic Violence Women only: Problems with breasts Menstrual problems Patients Signature and date signed