New Patient Forms

Patient’s Name

Nickname

Referring Physician

Address

City/State

Zip

Phone No.

(          )

Phone No. (Day) (          )

Sex (circle one)

Male          Female

Birth Date

S.S. #

Patient’s Employer

Occupation

Employer’s Address

Zip

Phone No.

(         )

Marital Status (circle one)

Single       Married        Widowed       Divorced

Age

Spouse’s Name

Spouse’s Employer

Notify in case of emergency

Address (street, city, state)

Phone No.

(         )

Notify in case of emergency (Not in household)

Address (street, city, state)

Phone No.

(         )

Dou have Medicare? (circle one)

Yes        No

Medicare Number

Do you have Medicaid? (circle one)

Yes        No

Medicaid Number

Do you have Texas Commission for the Blind? (circle one)

Yes              No

Counselor Name & City

Do you have Champus? (circle one)

Yes          No

If so, name of insured

Policy No.

S.S. #

Status (circle one) Active                Retired

Deceased

Do you have HMO or PPO? (circle one)

Yes          No

If so, name of company

Is pre-approval required? (circle one)

Yes          No

Address (street, city, state)

Zip

Contact Person

Phone No.

(         )

Name of Insurance Company (Private)

Policy No.

Is pre-approval required? (circle one)

Yes    No

Name if insured

Date of Birth of Insured

S.S. #

Patient’s relationship to insured

Address (street, city state, zip)

Name of Insurance Company (secondary)

Person to contact

Pre-approval required? (circle one)

Yes                No

Name of insured

Patient’s relationship to insured

Address (street, city, state, zip)

Is this a Worker’s Compensation Claim? (circle one)

Yes         No

Date of Injury

Contact person

Phone No.

(         )

Name:

Date:

Date of birth:

Address:

Telephone #:

Referring physician:

Telephone #:

Address:

Primary care physician:

Telephone #:

Address:

S

F

S

F

S

F

anemia

emphysema

arthritis

gout

kidney disease

asthma

heart attack

stroke

cancer

hepatitis

thyroid disease

diabetes

high blood pressure

vascular disease

Are you using non- prescription drugs?

no

yes,                                                                                                

Do you use street drugs?

no

yes,

Do you drink alcohol

no

yes, how much?

Do you smoke?

no

yes, how much?

Have you ever been exposed to the AIDS virus?

no

yes,                                                                                                

Have you ever had a sexually transmitted disease?

no

yes,                                                                                                

Do you get allergy shots?

no

yes,

Marital status:      single,      married,         widowed,     divorced,           other

Work status:             Current occupation:                                Previous occupation: Any known toxic exposure?  no / yes

Living arrangements:       home,         apartment,            nursing home,       other

Live alone?   yes / no                                  Status:        independent   /       need assistance

Education level:       high school,       college,       post-graduate degree,       other

Driving:

Do you drive in the day?        yes / no                                 with difficulty?        yes / no

Do you drive at night?            yes / no                                 with difficulty?        yes / no