Patient Demographics
Today's Date
 Patient's Legal Last Name
 First Name
 Middle Initial
 Patient Goes By
 Birth date
 Age:
 Social Security Number
 Sex:
 Male
Please provide at time of check-in
Female
Marital Status
 Spouse's Name (if applicable)
 Patient Street Address
 City
 State
 Zip Code
 Home Phone
 Work Phone
 Cell Phone
May we leave a message at your home number?
May we leave a message at your work number?
May we leave a message on your cell phone?
Which is your primary number?
May we leave a message with test results and/or medical advice on your primary phone?
Contact Person to Notify in Case of Emergency AND / OR share health / treatment information with:
Name
 Relationship to you
 Phone number
Employer (indicate if student)
 Occupation
Employer's Address
 City
 State
 Zip Code
Full time
Part time
NA
If patient is a student or a minor please enter parent's information:
Parent's Name
 Parent's Address
 City
 State
 Zip Code
 Parent's Employer
 Parent's Work Phone & ext
Primary Care Physician
 Phone Number
 Referring Physician
 Phone Number
Insurance Information
Primary Insurance
 ID number
 Group no.
 Co-pay
 Billing Address
 City
 State
 Zip Code
 Phone Number
Patient's relationship to subscriber
 Subscriber's Full Name
 Birth date
 Subscriber's Employer
Second Insurance
 ID number
 Group no.
 Co-pay
 Address
 City
 State
 Zip Code
 Phone Number
Patient's Relationship to Subscriber
 Subscriber's Full Name
 Birth date
 Subscriber's employer
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
Allergies
 **Current Medications (list drug name, dosage and prescribing doctor):
Height:
 Feet:
 Inches:
 Weight (lbs):
**If more than 5 medications
please bring in a list at check-in.
Please do not bring in your pills.
Past History
Have you had or do you have any of the following?
Heart problem
 Thyroid disease
 Diabetes
 High Blood Pressure
Surgical History
List all previous operations and dates:
**If more than 5 surgeries please
   bring in a list at check-in.
Surgical Risk Factors
Have you ever been treated for blood clots?
Where was the blood clot located?
 What side was the blood clot on?
Did you or your relatives experience problems with the following during or after surgery?
you or relative?
Bleeding disorder:
Anesthesia:
you or relative?
Did any of your relatives die during or soon after surgery?
Please explain:
Social History
Do you smoke?
 Did you ever smoke?
When did you quit?
Do you drink alcoholic beverages?
Type
Amount/Frequency
Have you ever used recreational drugs?
What type?
Are you at risk for HIV (AIDS)?
Please explain:
Family History
Please list any serious medical problems that your blood relatives have experienced
Relative:
 Problem:
 Living or Deceased?
Relative:
Living or Deceased?
Problem:
Relative:
 Problem:
Living or Deceased?
Systems Review
Choose any of the following symptoms or conditions you have had or now have.
To choose more than one option hold the Control (Ctrl) key down and select all options that apply.  If you're using a MAC use the Command key instead
of the Control key.  Each box must have at least one selection.  DO NOT USE THE SCROLL BAR ON YOUR MOUSE IN THIS SECTION!!
Bleeding Problems:
 Genital-Urinary:
 Gastrointestinal:
 Neurological:
Eye & Vision:
Ears & Hearing:
Psychological (emotional):
Nose & Throat:
Respiratory:
 Musculoskeletal:
Sleep:
Cardiovascular:
Other medical condition not already listed:
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.  You know we
have received your paperwork when you
see a stop sign at the end.  Thank you!
Patient feedback regarding our online form:
Did you find the online form easy to use?
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 Feedback
Comments:
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Please make sure you have enough time to complete this form because you cannot save it and return to it later.  It is recommended to have your medical history
information available to expedite this process.
Troubleshoot: If you cannot see the button at the bottom make sure the zoom on your screen is set to 100%.  If you have any problems with this form call our office at
517-394-3200 and ask for Sarina.  Thank you.