Registration & Medical History

1 Patient Registration

Patient name (Last, First, Middle Initial)

Date

Address

City, State

ZIP

Home phone

Cell phone

Date of birth

Sex

Male Female

Marital status

Single Married Other

Employer name (if any)

2 Parent / Legal Guardian (if patient is a minor or dependent)

Name (First, Last, Middle Initial)

Relation to patient

Spouse Parent Guardian

Address (if different from patient)

Home phone

3 Emergency Contact & Current Provider

Emergency contact name

Relationship

Phone number

Primary / family doctor (if any)

Referring doctor (if any)

4 Authorization to Release Health Information

Release information to (name)

Phone

Information to release

5 Allergies

Preferred pharmacy

Other allergies

6 Family History

Check any condition that an immediate relative has or had.

Condition	Mother	Father	Sibling
Arthritis
Cancer
Diabetes
Heart problems
Hypertension
Stroke
Thyroid disorder

7 Social History

Occupation

Status

Retired Disabled

8 Medical History

Check any condition you have had.

Other conditions

Surgical history (hospitalizations, surgeries, fractures, major illnesses — type and year)

Current medications (include over-the-counter; name, dosage, prescribing doctor)

Signature of Patient or Legal Representative

Printed name

Relationship to patient (if representative)

Date

Patient Registration & Medical History