Main Patient Form

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Patient Information

First Name

Last Name

Gender

Birth Date

Street

Apartment

City

State

Zip

Home Telephone

Cell

Have you ever been a patient of our practice?

Did you find our practice online?

Referred By

Preferred Pharmacy

Telephone

Personal Payment Type

Has a family member ever been a patient of our practice?

Driver’s Licence Number

Nearest relative not living with you

Telephone

Employer

Occupation

Business Telephone

In case of emergency, please contact

Telephone

Relation

Who will be responsible for your account

First Name

Last Name

S.S.#

Birth Date

Street

Apartment

City

State

Zip

Telephone

Employer

Business Telephone

Insurance Information

Student

School Name

School Address

Marital Status

City

State

Zip

Employed

Do you belong to a PPO or HMO?

Primary medical insurance company

Employer

Business Address

City

State

Zip

Business Telephone

Plan

Insurance Company Name

Address

City

State

Zip

Telephone

Group Name

Group #

Insured Party

Relation

Birth Date

Gender

S.S. #

Telephone

Address

City

State

Zip

Secondary medical insurance company

Employer

Business Address

City

State

Zip

Business Telephone

Plan

Insurance Company Name

Address

City

State

Zip

Telephone

Group Name

Group #

Insured Party

Relation

Birth Date

Gender

S.S. #

Telephone

Address

City

State

Zip

Health History

To our patients: Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today’s office visit?

Height

Weight

Are you in good health? .

Are you under the care of a physician?

Date of last visit

For what are you being treated?

Have you had any illness, operation or been hospitalized in the past five years?

Describe

Genetic Screening

Does anyone in the family have any of the following (includes patient, father of baby, and anyone in either family):

Is the patient’s age over 35 years as of estimated date of delivery?

Thalassemia (Italian, Greek, Mediterrean, or Asian background) MCV<80?

Neural Tube Defect (Meningomyelocele, Spina Bifida, or Anencephaly)?

Congenital Heart Defect?

Tay-Sachs (Jewish, Cajun, French Canadian)?

Sickle Cell Disease or Trait (African American)?

Hemophilia or other Blood Disorder?

Muscular Dystrophy?

Cystic Fibrosis?

Down Syndrome?

Intellectual Disability / Autism?

Other Inherited Genetic or Chromosomal Disorder? .

Family History

Have you or has the father of the baby had a child with a birth defect (spina bifida, hole in the heart, down syndrome, cleft lip)?

Describe

Did you or the father of the baby have a birth defect?

Describe

Please describe any abnormalities that have occured in children of your family or the father of the baby’s family (metal retardation, birth defects, deformities, or inherited diseases such as hemophilia, muscular dystrophy, or cystic fibrosis)?

How is the child / person related to you

Is the father of the baby over the age of 50?

Do you, or the father of the baby, have a history of pregnancy losses (miscarriages or stillbirths)?

Describe

Have you had or do you currently have

Rheumatic fever?

Damaged heart valves / mitral valve prolapse?

Heart murmur?

High blood pressure?

Low blood pressure?

Chest pain / angina?

Heart attack(s)?

Irregular heart beat?

Cardiac pacemaker?

Heart surgery?

Pneumonia, bronchitis, chronic cough?

Asthma?

Hay fever / sinus problems?

Snoring?

Sleep apnea / CPAP?

Difficult breathing / other lung trouble?

Tuberculosis?

Emphysema?

Do you smoke or vape? (If so, how much a day)

Blood transfusion?

Blood disorder such as anemia?

Bruise easily?

Bleeding tendency / abnormal bleed?

Hepatitis, jaundice, or liver disease?

Infectious mononucleosis?

Gallbladder trouble?

Fainting spells?

Convulsions / epilepsy?

Stroke?

Thyroid trouble?

Diabetes?

Low blood sugar?

Kidney trouble?

High cholesterol?

Are you on dialysis?

Swollen ankles / arthritis / joint disease?

Osteoporosis / osteopenia?

Osteonecrosis?

Acid reflux?

Stomach / GI troubles / ulcers / IBS / colitis?

Contagious diseases?

Sexually transmitted diseases?

Problems with immune system? Possibly from medication / surgery, etc.

Delay in healing?

A tumor or growth?

Cancer / radiation therapy / chemotherapy?

Chronic fatigue / night sweats?

Are you on a diet?

A history of alcohol abuse?

A history of marijuana or other drug use?

Contact lenses?

Eye disease / glaucoma?

Mental health problems / anxiety / depression?

A removable dental appliance?

Pain or clicking of jaws when eating?

Are you allergic to, or had a reaction to

Local anesthetic (numbing meds.)?

Penicillin?

Other antibiotics?

Sulfa drugs?

Sodium pentothal / Valium / other tranquilizers?

Aspirin?

Amoxicillin?

Codeine or other narcotics?

Other medications?

Latex?

Soy?

Eggs / yolk?

Sulfites?

Do you have any known allergies?

Please list any allergies other than drug allergies:

Is there any condition concerning your health that the Doctor should be told about?

Describe

Do you wish to speak to the Dr. privately about anything?

Are you now taking

Any kind of medication, drug, pills?

Please list any medications you are currently taking:

Medication

Dosage

Frequency

Pregnancy Information

Due Date

First Day of Last Menstrual Period

Dated by

Gynocological History

Current Weight

Height

Date of Last Pap Smear

Have you ever had an abnormal pap smear?

When

Any procedures on your cervix (biopsy, LEEP, CRYO surgery, colposcopy)?

Describe

Any uterine abnormality?

Fibroids?

Bicornuate uterus?

Any infertility problems?

Describe

Is this pregnency?

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Location

Patient Information

Its Paid by

Primary Insurance

Secondary Insurance

Patient Information

Who will be responsible for your account

Insurance Information

Primary medical insurance company

Secondary medical insurance company

Health History

Genetic Screening

Family History

Have you had or do you currently have

Are you allergic to, or had a reaction to

Are you now taking

Pregnancy Information

Gynocological History

Thank You!

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