PATIENT DEMOGRAPHICS. Mailing Address: Apt: City: State: Zip Code:
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1 + ReenaMD NEW PATIENT FORM PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Marital Status: Birth Date: Age: Sex: / / Guardian's Last Name (if patient is a minor): Guardian's First Name: Relationship to Patient: Guardian's Social Security No.: Please mark the box of your preferred phone contact! Home Phone: Driver's License No. / State: Occupation Status:! Full- Time! Student /! Work Phone: address: Occupation:! Cell Phone: Other Family Members Seen Here: Employer:! Part- Time! Retired Preferred Pharmacy.: Pharmacy Phone No.:! Currently Unemployed! Disabled ADDITIONAL DEMOGRAPHICS: These questions are required to comply with new Federal Health guidelines- every patient is asked this information Race (check one): Ethicinity (Check one):!american Indian/Alaskan Native!Black/African American!Hispanic or Latino!Not Hispanic or Latino!Unknown!White!Asian!Native Hawaiian/Pacific Islander!Other Preferred Language (Check One):!English!Spanish!Other : INSURANCE INFORAMTION Primary Insurance Company: Effective Date: Policy Holder Name: Policy #: Group #: Secondary Insurance Company: Effective Date: Policy Holder Name: Policy #: Group #: Responsible Party: Legal Guardian/Parent with custody of minor: Relationship: Phone number: IN CASE OF EMERGENCY First Name of Contact: Last Name of Contact: Relationship to Patient:! Home Phone:! Work Phone:! Cell Phone: I ALLOW MY MEDICAL INFORMATION TO BE RELEASED TO: First Name: Last Name: Relationship to Patient: First Name: Last Name: Relationship to Patient:
2 MEDICAL HISTORY 2 Name : Date of Birth: Reason for today s visit: Date: DRUG ALLERGIES: ALLERGY REACTION MEDICATIONS: Please list all prescription & over-the-counter medications, vitamins, herbals that you are taking: PRIOR OR CURRENT MEDICAL HISTORY: ANEMIA ARRHYTHMIA ARTHRITIS BLOOD DISORDER/BLOOD CLOTS CANCER (TYPE) COPD DIABETES DEPRESSION HEART ATTACK (DATE) HIGH BLOOD PRESSURE HIGH CHOLESTEROL KIDNEY DISEASE MIGRAINES THYROID DISEASE STROKE (DATE) OTHER:
3 MEDICAL HISTORY 3 PREVIOUS SURGERIES, SERIOUS ILLNESS, AND/OR HOSPITALIZATIONS: CONDITION/EVENT YEAR FAMILY HISTORY: (Please indicate immediate family for all/any that apply) Disease Family Member Age of Onset/Death Asthma Colon Cancer Diabetes Depression Female Cancers (breast, ovarian, cervical, uterine) Heart Attack High Blood Pressure High Cholesterol Thyroid disease Prostate Cancer Skin Cancer Stroke GYN HISTORY: Please indicate the number of pregnancies and deliveries below: Pregnancies Live Births Vaginal Delivery C-sections Miscarriage Abortions Menarche (Age of first period)? Date of last menstrual period? Are your periods regular or irregular? Flow (light/moderate/heavy) Menopause? What age?
4 SOCIAL HISTORY: MEDICAL HISTORY 4 Occupation: Marital Status: #of children: boy girl ACTIVITY LEVEL: Do you exercise regularly? What type(s)? How many times/week? CAFFEINE: Do you drink caffeine? What type(s)? How many cups/day? TOBACCO: Never smoked regularly I used to smoke cigarettes/packs (circle one) per day/week/month (circle one) for years, but I quit in I currently smoke cigarettes/packs (circle one) per day/week/month (circle one) for years **Please let us know if you are interested in quitting! ALCOHOL: Do you currently drink alcohol? What type(s)? I drink (number of drinks) every (day/week/month) Is your alcohol a concern for you or others? DRUGS: Do you use recreational drugs? What type(s)? Have you ever used injected drugs?
5 MEDICAL HISTORY 5 SEXUAL ACTIVITY: Have you ever been sexually active? Currently sexually active? Sexual preference (male/female/both): Birth control method: Have you ever had a sexually transmitted disease (STD)? Are you interested in being screened for STDs? HEALTH MAINTENANCE: Date of Immunizations: Flu shot: Tetanus: Pneumonia vaccine: Shingles vaccine: Date of: Last Physical Last of Blood Tests Colonoscopy For Men: Last PSA (prostate test) For Women: Last Mammogram Pap Smear Bone Density
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