Patient Registration Forms
Patient Information
Today's Date *
(## / ## / ####)
Patient's Last Name *
First Name *
Middle Initial
Patient Goes By
Birth Date *
(## / ## / ####)
Age *
Social Security Number
  
Sex *
Marital Status *
Spouse's Name
Patient Address *
City *
State * (i.e. MI)
Zip Code *
Home Phone
(### - ### - ####)
Work Phone
(### - ### - ####)
Cell Phone
(### - ### - ####)
Email Address
Contact Person to Notify in Case of Emergency
Name *
Phone Number *
(### - ### - ####)
Primary Care Physician *
Phone Number
(### - ### - ####)
Referring Physician
Phone Number
(### - ### - ####)
Patient Employment Information                                                                                Parent Information for Students and Minors
Employer (indicate if student) *
Occupation
Employer's Address
Employer's City
Employer's State
Employer's Zip Code
This information is required for patients who are students and/or minors *
Parent Information for Students and Minors
Parent's Name
Parent's Employer
Parent's Work Phone & Ext.
Parent's Address
Parent's City
Parent's State
Parent's Zip Code
Insurance Information
Primary Insurance
Insurance Name *
Subscriber's Full Name *
Subscriber's Birth Date *
(## / ## / ####)
Patient Relationship to Subscriber *
Second Insurance
Insurance Name
Subscriber's Full Name
Subscriber's Birth Date
(## / ## / ####)
Patient's Relationship to Subscriber
Is this a Worker's Compensation case? *
Is this a No-Fault claim (auto accident)? *
Is this a Legal/Third Party Liability case? *
Medical History
Height: Feet *
Inches *
Weight (lbs.) *
List all allergies *
(drugs, latex, tape, food)
1.
2.
3.
4.
5.
List all medication names (include non-prescription) *
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
List previous surgeries and what year they were performed *
Operation
Year
1.
2.
3.
4.
5.
6.
**If more than 12 medications
please bring in a list at check-in.
Please do not bring in your pills.
**If more than 6 surgeries please    
bring in a list at check-in.
To your knowledge, do you have now or have you ever had any of the following: *
Yes No
  
Cancer
Diabetes
Heart Disease/Failure
Heart Murmur/Mitral Valve Prolapse
High Blood Pressure
   
AIDS/HIV Positive
Asthma
Bleeding/Bruising Tendencies
Lung Disease/Emphysema
MRSA / VRE Infection
Stroke
Thyroid Disease
   
Do you smoke?
If yes, how many packs per day?
Have you ever smoked?
Do you drink alcohol?
If yes, quantity per week
Do you use street drugs?
If yes, what drug(s)?
Yes No
  
Arthritis
Blood Transfusion(s)
Blood Clots (DVT)
Phlebitis
Kidney Disease
Liver/Disease/Hepatitis
Stomach Ulcer / GERD
Tuberculosis
Hearing or Vision Problems
Nose or Throat Problems
Epilepsy / Seizures
Depression/emotional
illness/panic attacks
Sleep apnea
Insomnia
Could you be pregnant?
Other medical condition not already listed
max 50 characters
Have you ever had complications with surgery? *
If yes, explain
Any bleeding disorder problems with you or your relatives during or after surgery? *
If yes, explain
Any anesthesia problems with you or your relatives during or after surgery? *
If yes, explain
Have you had a bone density test? *
If yes, when
Regarding Today's Visit
What area of the body are you scheduled to be seen for? *
Which side (right, left, bilateral)? *
Give a brief description of the problem.
i.e. What were you doing? How did the injury occur? *
Date of Injury (if no injury write N/A) * (## / ## / ####)
How long have you had this problem?
Pain level at time of injury (1-barely any, 10-unbearable)
What tests have you had done for this problem and when?
max 80 characters
Have you had a previous injury or trauma to this area? *
Have you had any surgery to this area? *
If yes, what and
when?
Have you seen someone else for this
problem? *
If so, whom?
       
Are you right or left handed? *
Confidentiality / HIPAA
                                                                                                                                                                                Yes      No      NA
May we leave a message at your home requesting a return call? *
May we leave a message at your home regarding appointment scheduling? *
May we leave a message at your home with test results and/or medical advice? *
May we leave a message at your work requesting a return call? *
May we leave a message at your work regarding your health care? *
May we leave a message on your cell requesting a return call? *
May we leave a message on your cell regarding appointment scheduling? *
May we leave a message on your cell with test results and/or medical advice? *
May we speak with someone other than you regarding you treatment? If yes, please list below: *
Name:
Relationship:
 
Name:
Relationship:
 
May we speak with your employer regarding your treatment? *
May we fax information to your employer regarding your treatment? (For example, work release form etc.) *
You must review your information before it can
be submitted.  Please press the button below
when you are ready to review your information.  
On that page you will submit your information.  
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