As a new patient, you have a lot of background to share with us. Use this template when you are visiting  for the first time. Fill this out to bring with you to the appointment to simplify the registration process. Keep a copy for your records so that it is available when you need to visit other doctors.

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page after entering the data so you don't lose your information.

Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney, cancer or other medical problems?    

 Yes      No

Please list any conditions and select how the person is related to you.

Condition:		Relationship:	MotherFatherSiblingPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherAuntUncleCousin
Condition:		Relationship:	MotherFatherSiblingPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherAuntUncleCousin
Condition:		Relationship:	MotherFatherSiblingPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherAuntUncleCousin
Condition:		Relationship:	MotherFatherSiblingPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherAuntUncleCousin
Condition:		Relationship:	MotherFatherSiblingPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherAuntUncleCousin

List your current physicians.

	Specialty:
	Specialty:
	Specialty:

Enter the date of your last physical exam and list the physician who saw you.

Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Date:	12345678810111213141516171819202122232425262728293031	Year:	1999199819971996199519941993199219911990
Physician:

(Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.

Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Date:	12345678810111213141516171819202122232425262728293031	Year:	1999199819971996199519941993199219911990
Physician:

List any medical conditions you have and for how long you've had the condition (first month/year diagnosed)

Condition:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Condition:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Condition:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Condition:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Condition:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:

Have you ever gone to an emergency room for treatment in the last year?    

 Yes     No
How many times in the past year? 
List the reason and when you made each ER visit.

Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:

Have you ever stayed in the hospital overnight during the past year?    

 Yes     No
How many times in the past year? 
List the reason and when you stayed overnight.

Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:

Have you had surgery?    

 Yes     No

List the type of surgery or reason for surgery including dates.

Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:
Reason:		Month:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year:

List any allergies you have to food or medications.

Tip: Only 5 lines available, so summarize.

Have you ever had an anaphylactic reaction (turning red, overall swelling, difficulty breathing)?    

 Yes     No

Do you smoke?     Yes     No

Select which products you use, how much, and number of years used.

Tobacco product:	CigarettesCigarsPipesTobacco ChewMore than 1
How much:
Years:

Do you drink alcohol?    

 Yes     No

Beer:

none12345678910 or more

Wine:

none12345678910 or more

Liquor:

none12345678910 or more

Do you take any recreational drugs?

     Yes     No

Are you taking any prescription drugs currently?

     Yes     No
List drugs, dosage, and how often you take them.

Drug Name:		Dosage:		How often:	DailyMultiple times/dayWeeklySeveral times/weekMonthlySeveral times/monthAs needed
Drug Name:		Dosage:		How often:	DailyMultiple times/dayWeeklySeveral times/weekMonthlySeveral times/monthAs needed
Drug Name:		Dosage:		How often:	DailyMultiple times/dayWeeklySeveral times/weekMonthlySeveral times/monthAs needed

To avoid errors, bring in any medications your child takes in their original bottles.

Tip: Only 5 lines available, so summarize.

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.

| 15.05.2006 | Read more | Print |