New Patient Registration Form

Patient Information:

Sex:

May we leave a message on an answering machine or with a family member?

May we email or mail you information on services offered by our office?

MARITAL STATUS

SPOUSE:

PATIENT EMPLOYMENT INFORMATION:

PRIMARY INSURANCE:

EMERGENCY CONTACT INFORMATION :
(a relative or friend not living with you):

MEDICAL QUESTIONNAIRE:

SERIOUS MEDICAL PROBLEMS:

CURRENT MEDICATIONS:
Name, Does, How Often, Date Last Taken

DO YOU TAKE ASPIRIN ON A REGULAR BASIS?

DO YOU HAVE A PACEMAKER?

ALLERGIES:

Are you allergic to any medication?

What type of reaction do you have?

Do medications have an unusual effect on you?

Are you allergic to adhesive tape?

Are you allergic to iodine?

Please list any other allergies:

HABITS:

Do you have alcoholic beverages more than 2‐3 times per week?

Do you smoke?

PAST SURGICAL HISTORY:
Date, Operation, Surgeon, Hospital

MEDICAL QUESTIONNAIRE:

PAST MEDICAL HISTORY:
Have you ever had any of the following?:

REVIEW OF SYSTEMS:
Do you now or have you had within the past year any of the following?:

FAMILY HISTORY:
​​​​​​​

Have you ever had a blood transfusion?

Do you have any metal in your body?

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