MARSHALL FAMILY PRACTICE REGISTRATION FORM

MARSHALL FAMILY PRACTICE REGISTRATION FORM

PATIENT NAME: Birth date:

ADDRESS: Social Security #:

Street, Apt. No.

City: State: Zip:

Home Phone:( ) County: Sex: Race: Religion:

MAIDEN NAME: (Single patients or male patients give mother=s maiden name)

Single ____ Married ____ Widowed ____ Separated ____ Divorced ____

PATIENT EMPLOYER

NAME: ADDRESS:

Employer Phone: ( )

Street, Appt.. No. City, State, Zip

Occupation:___________ Employment Status: Full Time__ Part Time __ Retired __Unemployed __

PERSON TO NOTIFY

NAME: ADDRESS:

Phone: ( ) Relationship:

NEXT OF KIN (If same as person to notify leave blank)

NAME: ADDRESS:

Phone: ( ) Relationship:

GUARANTOR (Who is responsible for bill: Self or (Who is bringing pt in today if minor NOT INSURANCE )

NAME: ADDRESS:

Phone: ( ) S.S. Number:

GUARANTOR EMPLOYER

NAME: ADDRESS:

EMPLOYMENT STATUS: OCCUPATION_____________

EMPLOYER PHONE: ( )

IF PATIENT IS A MINOR WE NEED BOTH PARENTS EMPLOYMENT INFORMATION. THIS SECTION IS FOR THE PARENT THAT IS NOT LISTED IN THE GUARANTOR INFORMATION ABOVE.

NAME: ____________________________SS#__________________DATE OF BIRTH____________

ADDRESS_____________________________ RELATIONSHIP TO PATIENT___________

EMPLOYER ADDRESS __________________PHONE:_____________

EMPLOYMENT STATUS______________________

INSURANCE POLICY NUMBER COVERAGE NO. SUBSCRIBER REL OFFICE COPAY

Primary Care Physician: Reason for Visit:

READ AND SIGN

I hereby authorize payment directly to my physician=s office, of any Insurance coverage for treatment rendered, and authorize them to release any information necessary to process these insurance claims.

I understand that I am fully responsible for all social services and charges, including any balance due after payment of insurance, and that insurance coverage does not necessarily pay all charges.

I also understand that doctor and office fees are due and payable when services are rendered.

I, the undersigned, authorize treatment by the physician of this office.

SIGNATURE:

(If Minor, Parent or Guardian Signature)

DATE_______________________

MARSHALL FAMILY PRACTICE PATIENT HEALTH HISTORY

PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY

Name: Birth Date __________________________

Age Sex Marital Status _____ Occupation ____________________

PAST HEALTH HISTORY

Please list all previous hospitalizations, surgeries, injuries, and blood transfusions. Include dates, hospitals, and physicians.

_______________________________________________________________________

CURRENT HEALTH STATUS

ALLERGIES: ______________________________________________________________

________________________________________________________________________

Please Include Any Medications, Foods, Or Other Things To Which You Are Allergic

CURRENT MEDICATIONS: Please List all medication which you are currently taking.

(Be Sure To Include Over The Counter Contraceptives And Medications Taken Only Occasionally)

Name of Medication

Strength

How Often

Date Began

Date Last Taken

HAVE YOU EVER HAD ANY OF THE FOLLOWING?

HIGH BLOOD PRESSURE Y N BLEEDING DISORDER Y N

HEART DISEASE Y N THYROID DISORDER Y N

STROKE Y N LIVER DISEASE Y N

DIABETES Y N EPILEPSY/SEIZURES Y N

CANCER Y N ASTHMA Y N

LUNG DISEASE Y N KIDNEY DISEASE Y N

ULCERS Y N ALCOHOL/DRUG ADDICTION Y N

ARTHRITIS Y N ANXIETY Y N

HEADACHES Y N DEPRESSION Y N

ANEMIA (LOW IRON) Y N H. I. V. Y N

Please list other illnesses which you think would be important to your care.

_________________________________________________________________________

LIFE HABITS

#1 Do You Or Have You Ever Used Tobacco, In Any Form? Y N

Age Started Age Quit Type And Amount __________

#2 How Much Coffee, Tea, And/Or Soda Do You Drink In A Day?

#3 How Much Alcohol Do You Drink?

Daily Weekly Less Than 3/Month Never

#4 How Many Hours Of Sleep Do You Get Within A 24 Hour Period?

Do You Generally Feel Rested? Y N

#5 What Type Of Exercise Do You Practice? Running Aerobics

Walking _____ None Other ________________

#6 What Activities Do You Do For Fun? ________________________________________

#7 Former schooling _______________________________________________________

#8 Occupation____________________________________________________________

FAMILY HEALTH HISTORY

To your knowledge, do any of your immediate family members have the following? If Yes WHO?

High Blood Pressure Bleeding Disorder

Heart Disease Thyroid Disorder

Stroke Liver Disease

Diabetes Epilepsy/Seizures

Cancer Asthma

Lung Disease Kidney Disease

Ulcers Alcohol/Drug Addiction

Arthritis Anxiety

Headaches Depression

Anemia (Low Iron) H. I. V.

__________________________________________________________

PATIENT=S SIGNATURE DATE