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1 REGISTRATION 329 Sanford Drive, Morganton, NC TEL: (828) Morganton Blvd. SW, Suite D, Lenoir, NC TEL: (828) rd Avenue NW, Hickory, NC TEL: (828) NEW PATIENT CHANGE OF ADDRESS PATIENT INFORMATION PATIENT S ADDRESS First Middle Last Street City State Zip Code OF BIRTH SEX M F S S # MARITAL STAUTUS S M D W Home Cell EMPLOYER EMERGENCY CONTACT PRIMARY CARE PHYSICIAN Name City Tel # RESPONSIBLE PARTY INFORMATION Same as Patient GUARANTOR S ADDRESS First Middle Last Street City State Zip Code OF BIRTH SEX M F S S # RELATION TO PATIENT Home Cell EMPLOYER INSURANCE INFORMATION ATTACHED NONE I hereby authorize the Greenway Family Practice / Greenway Health to release medical information to any of my physicians or insurance companies that may be pertinent to my case. I hereby authorize payment to the Greenway Family Practice / greenway Health of benefits otherwise payable to me. I hereby authorize release of my medical records to third party insurance or other authorized persons to whom disclosure is necessary to establish or collect fee for service provided. I understand that I am financially responsible for charges not covered by this authorization. A photocopy of this authorization shall be considered valid as the original. Medicare Patients: I authorize the Greenway Family Practice / Greenway Health to release medical information about me to the Social Security Administration or its intermediaries for my Medical Claims. I assign the benefits payable for services to the Greenway Family Practice. Patient or Guarantor s Signature: Date: / /
2 PATIENT MEDICAL HISTORY PATIENT Date of Birth RACE SEX M F PRIMARY CARE PHYSICIAN NONE TOWN / STATE TEL PREFERRED PHARMACY: Most Recent: Date (Year) Most Recent: Date (Year) Most Recent: Date (Year) Blood Work Mammogram PSA/prostate exam EKG PAP Smear Flu Shot Colonoscopy DEXA Scan Tetanus shot MEDICAL HISTORY SURGICAL HISTORY NONE Heart Disease NONE Gastric bypass Allergies (seasonal) High Blood Pressure Appendix Hernia repair Arthritis High Cholesterol Back Hysterectomy (total/partial) Anxiety Kidney disease Bladder Joint replacement: Asthma, COPD Liver disease/hepatitis Breast Tonsils Cancer:.. Stroke C-section Tubal ligation Chronic Pain Seizures Cosmetic/Plastic: Other:.. Depression Sleep apnea Gallbladder Diabetes Thyroid disease OB/GYN HISTORY Glaucoma or Cataracts Bladder/Urinary problems NONE IUD Acid Reflux/Stomach problem Other:.. Pregnancy: # Other:.. Headaches (Migraine/other) Miscarriage/Abortion Abnormal Pap Smears Colposcopy SOCIAL HISTORY FAMILY HISTORY (Father and Mother ONLY If appropriate, please note with M or F) Tobacco use NONE Kidney disease Seizures Amount/day: Cancer of Asthma, Emphysema, COPD Thyroid disease Alcohol use Diabetes Obesity Drinks/week: Heart disease Psychiatric illness Other:. Drug use High Blood Pressure Stroke Type/amount: ALLERGIES NONE Latex/Dye Environmental... CURRENT MEDICATIONS (Include Vitamins, Herbals, & Supplements) DOSE TIMES/DAY Medication.... To the best of my knowledge, the above information is accurate and complete. I understand that the above information is crucial to my medical care and can be used for billing my insurance. I will not hold any provider or any staff member at Greenway Family Practice responsible for an error or omissions that I may have made in completing this form. Patient s Signature:.. Date.
3 SOCIAL HISTORY Are you Have you ever been arrested? [] Single [] Yes [] Married [] No [] Separated If yes, you have been arrested for [] Divorced [] DWI [] In a long-term relationship [] DUI [] [] Drug-related offense If you are married [] Domestic violence [] For how long : [] [] How many times : Have you been abused? If you are in a long-term relationship [] Verbally [] For how long : [] Emotionally How many children do you have? [] Physically [] None [] Sexually [] Boys : [] Rape ( attempted ) [] Girls : [] Rape Where do you currently live? [] City / State Have you ever attended [] [] AA Who do you live with? [] NA [] Alone [] CA [] Spouse/Significant other [] ACOA [] Family member [] [] Friend Do you currently attend [] [] AA What education did you complete? [] NA [] High school [] CA [] College [] ACOA [] Graduate school [] [] Postgraduate If you do not, why not? [] Do you currently work? [] Yes Have you ever been in counselling? [] No [] Yes Where do you work? [] No Are you currently having counselling? [] Yes For how long did you work there? [] No REVIEWED BY : MD
4 ADDICTION HISTORY How did you start the addiction? How did you start the recovery? What medication did you use during recovery? When did you start Suboxone? What is the form and dose of Suboxone you are currently taking? Date [] Suboxone Tab 2/2.5 [] Zubsolve Sublingual Tabs 1.4/0.36 Who prescribes Suboxone? [] Suboxone Tab 8/2 [] Zubsolve Sublingual Tabs 5.7/01.4 Dr. [] Suboxone Sublingual Film 2/0.5 [] Zubsolve Sublingual Tabs 8.6/2.1 City/State [] Suboxone Sublingual Film 4/1 [] Zubsolve Sublingual Tabs 11.44/2.9 [] Suboxone Sublingual Film 8/2 [] Zubsolve When did you take the last dose of Suboxone? [] Suboxone Sublingual Film 12/3 Others Date [] Suboxone Time Side effects [] mouth numbness ( ) fast or slow heart rate [] anxiety ( ) nausea and vomiting [] headache ( ) irregular heart rate [] restlessness ( ) abdominal cramping [] dizziness ( ) shallow breathing [] inability to sleep ( ) diarrhea [] numbness or tingling ( ) difficulty waking up [] yawning very often ( ) dilated pupils [] vomiting others [] runny nose ( ) blurry vision [] constipation [] lacrimation (eyes tearing up) ( ) goose bumps on the skin [] stomach pain [] excessive sweating ( ) rapid heartbeat [] drowsiness [] muscle aches ( ) high blood pressure [] feeling drunk others [] trouble concentrating [] trouble sleeping REVIEWED BY : MD
5 SUBSTANCE USE HISTORY SUBSTANCE NO YES PAST / NOW ROUTE HOW MUCH HOW OFTEN LAST USED QUANTITY LAST USED ALCOHOL CAFFEINE Pills, Beverages.. COCAINE CRYSTAL METHAMPHITAMINE HEROIN PAIN PILLS Percocet, Vicodin.. METHADONE STIMULNATS Adderall, Ritalin.. SEDATIVES Xanax, Klonopin.. SLEEPING PILLS Valium, Ativan.. MARIJUANA ECSTACY LSD PCP INHALANTS OTHERS REVIEWED BY MD
6 MENTAL HEALTH QUESTIONNAIRE Do you feel: Have you been admitted to a psych Highest education completed: [] ANXIOUS hospital? [] Less than High School [] DEPRESSED [] Yes [] High School [] [] No [] College How long have you felt this way? Have you had suicidal thoughts? Do you work? [] Less than 2 Weeks [] Yes [] Yes Where? [] More than 2 Weeks [] No [] No [] Months Have you attempted suicide? Marital Status: [] Years [] Yes How? [] Single Do you feel anxious or depressed due to the following? [] No [] Married 1 2 More Have you had? [] Separated [] Spouse [] Paranoid Thoughts [] Divorced [] Children [] Voices In Your Head [] Widowed [] Finances [] A Feeling that every thing is not real Do you have children? [] Work Have you been convicted of crimes? [] None [] Health [] No [] 1-2 [] No Obvious Reason [] Yes Explain: [] 3 4 [] [] More than 4 Do you have any of the following? Is there a family history of: Do you use: [] No Energy [] Anxiety [] Alcohol how much? [] Restlessness [] Depression [] Extra Prescription Medication [] Difficulty Falling a sleep [] Bipolar Disorder [] Street Drugs which? [] Difficulty Staying awake [] Schizophrenia Do you have other medical issues? [] Increased Appetite [] Suicidal Thoughts [] Fibromyalgia [] Decreased Appetite [] Suicide Attempts [] Back Pain [] Difficulty in concentrating [] Substance Abuse [] Migraine Headache [] No interest in things that you used to [] Psychiatric hospitalization [] [] [] What makes you more anxious? What makes you less anxious? Have you been evaluated by anyone? [] Going Home [] Talking to a friend [] Psychiatrist [] Going to work [] Going out [] Psychologist [] Talking to people [] Sports [] Neurologist [] Going out [] Being alone [] Therapist [] [] [] Medication that has helped: Medication that did NOT help: Side effects from medications: [] Paxil, Celexa, Lexapro, Prozac, Zoloft [] Paxil, Celexa, Lexapro, Prozac, Zoloft [] [] Effexor, Cymbalta, Pristiq, Wellbutrin [] Effexor, Cymbalta, Pristiq, Wellbutrin [] [] Xanax, Klonopin, Ativan, Valium [] Xanax, Klonopin, Ativan, Valium [] [] Ambien, Lunesta [] Ambien, Lunesta [] [] Restoril [] Restoril [] [] Amitriptyline [] Amitriptyline [] Seroquel, Zyprexa, Lithium [] Seroquel, Zyprexa, Lithium [] [] Reviewed by MD/FNP
7 CHRONIC PAIN QUESTIONNAIRE When did your pain start? Days Months Years What caused your pain? Auto Accident Work Accident Medical Illness Has your pain changed? Same Better Worse Would you describe your pain as? In one area Radiates to other areas Radiates to : How would you rate your pain? [ 0 ] [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] none mild moderate severe Please mark where your pain occurs: How does your pain feel? How frequent is the pain? What time of day is your pain worst? Sharp Aching Dull Throbbing Burning Pins & Needles Daily Most days of the week Few days a week Few days a month Morning Day Evening Night What makes the pain worse? What makes the pain better? Has the pain caused any: Nausea Nothing Bending Nothing Cold Vomiting Sitting Coughing Sitting Heat Blurred vision Standing Weather Standing Medicine Dizziness Lying Down Lying Down Bladder or Bowel Problems Lifting Rest What has the pain made it difficult for you to do? Drive a car Prepare meals Use telephone Use the toilet Climb stairs Take a bath Get dressed Brush your hair Shop for groceries Perform house work Perform sex Does the pain make you feel: Anxious Depressed Frustrated Hopeless Who has treated your pain? What tests have been done? What treatments have you tried? Family doctor Internist Neurologist Orthopedic Gynecologist Pain Clinic Chiropractor Lab Tests X-Rays CAT Scan MRI Nerve Tests Other: Physical therapy Nerve Block Epidural Injections Steroid Injections All the time Other: Weight loss Weight gain NONE Other: Helpless Tired TENS Surgery Other: How soon do you think the following will be possible: You will be able to work Days Months Years Never You will have no pain Days Months Years Never You will be able to discontinue strong pain medications / narcotics Days Months Years Never Have you ever: Been admitted to Psychiatric Ward Yes No Attempted Suicide Yes No Overdosed on drugs Yes No Reviewed by: MD/FNP
PATIENT FINANCIAL AGREEMENT
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I Federal Law requires us to ask race: Hispanic Non-Hispanic
Today's Date < McCoy VISION Please Contact Me at this Number Patient Registration Chart# - Patient's Name (last, first, middle initial) Date of Birth Sex Home Phone Street Address City State Zip Work
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Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
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William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español
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PARKWEST GYNECOLOGY, P.C. 9330 Parkwest Blvd., Suite 302 Knoxville, TN 37923 (865) 531-5878 PATIENT REGISTRATION FORM Please complete form using your legal name as it appears on your social security card.
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU
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Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
3. Should you be unable to keep your appointment, please call us at (209) to cancel or reschedule, as soon as possible.
To Our Patients, Welcome to the family practice office which has served Ripon and surrounding communities since the early 1970 s. We look forward to providing you with quality medical care. The following
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entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary Phone Secondary Phone Emergency
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
PATIENT RECORD Please fill out completely. Thank you. Referring Physician. Last Name Legal First Name MI
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