New Child Registration Date: / / Insurance Information Primary insurance Primary Reason for today s visit: Last Name, First, MI Mailing address City, State, ZIP Which pharmacy do you use? Insurance Co. ID#: Grp#: Policy Holder s Name: SS# / / Sex: M F Birth Date: / / Date of Birth / / Race White Black/African American Asian Other Relationship to patient: Ethnicity Hispanic Origin Non Hispanic Origin Language English Other Parent/Guardian Name Mailing Address City, State, Zip Secondary Insurance Insurance Co. ID# Group # Home Phone: - - Cell Phone: - - Policy Holder s Name: Sex: M F Birth Date: / / Social Security # - - SS# / / Date of Birth / / In case of an emergency who do we contact? Relationship to Patient: Name Phone
Chief Complaint: (Briefly describe the main reason(s) for coming to the Dr today) Other Medical Problems: Childhood Illness: Family History: (Circle the appropriate letter pertaining to that family member) M=Mother F=Father B=Brother S=Sister M F B S = ADHD M F B S = Developmental Delay M F B S = Osteoporosis M F B S = Alcoholism M F B S = Diabetes M F B S = Osteoarthritis M F B S = Allergies M F B S = Eczema M F B S = Renal Disease M F B S = Alzheimer s M F B S = Hearing Deficiency M F B S = Seizure Disorder M F B S = Asthma M F B S = Hyperlipidemia M F B S = Hypolipidemia M F B S = Blood Disease M F B S = Hypertension M F B S = Hypotension M F B S = CAD M F B S = Cancer M F B S = Irritable Bowel M F B S = Learning Disability M F B S = CVA M F B S = Mental Illness M F B S = Depression M F B S = Obesity M F B S = Other Circle all that apply: Does your child drink coffee/tea Y or N Caffeine: Yes or No Type: Chocolate Coffee Soda Tablets Tea Does he/she follow a particular diet? Y or N Does he/she exercise regularly? Y or N Has your child been exposed to smoke (Cigarettes, Cigar, Pipe, Smokeless) Y or N Frequency: Daily Weekly Monthly Yearly Occasionally Rarely Socially
Medications: Name: Directions: Reason ALLERGIES: REACTION: Please Circle All That Apply: Date Last Done: Colonoscopy YES NO / / Flu Vaccine YES NO / / Pneumonia Vaccine YES NO / / Tetanus Vaccine YES NO / / Dexa Scan (Bone Density) YES NO / / Pap Smear YES NO / / Mammogram YES NO / / Cardiac Stress Test YES NO / / Echocardiogram YES NO / / Eye Exam YES NO / / Foot Exam YES NO / / PFT (Pulmonary Function Test) YES NO / /
Chronic Conditions: (circle all that applys) ADHD Afib Alcohol Dependence Allergic Rhinitis Alzheimer s Anemia Angina Anticoagulant use Anxiety Asthma Bipolar Cancer of Cardiac Dysrhythmia Cervicalgial COPD Congestive Heart Failure (CHF) Dementia Crohn s CVA Depression Diabetes Dialysis Downs Syndrome Gastric Ulcer GERD Gout Headaches Hepatitis Herpes HIV Hypertention Hypotension Hyperlipidemia Hypolipidemia Insomia Irritable Bowel Kidney Disease Lupus Mental Illness Obesity Seizure Disorder Osteoporosis Pacemaker Psoriasis Renal Failure Other: ================================================================================================ Past Medical History: Allergies Anemia Angina Anxiety Asthma Blood Clots Cancer of CVA Depression Gallbladder Disease GERD Liver Disease Migraine Peptic Ulcers Seizure Disorder Thyroid Disease Other: ============================================================================================= Past Surgical History: Angioplasty Carpel Tunnel Release Knee Replacement Angio with Stent Cataract Extraction Lasik Appendectomy Cholecystectomy (gallbladder) Liver Biopsy Arthroscopy Knee Colectomy Mastectomy Back Surgery C-Section ORIF Bowel Resection D and C Pacemaker Gastric Bypass CABG Thyroidectomy Breast Biopsy Hernia Repair Tonsillectomy Hysterectomy Breast Reduction Breast Augmentation Hip Replacement Tubal Ligation Other:
Dear Valued Patient, With Franklin County Family Health Center Patient Portal, you not only access your medical record, but also a wealth of general information online. When you log in, you can easily view new messages from the practice or take advantage of its many powerful features offered: Request or confirm an appointment Correspond with your doctor and clinic electronically Receive appointment reminders View medication list and request prescription refills View and request your medical records View Lab and X-Ray results Patient Name: DOB: Today s Date: Guardian s Email Address: Would you like to have online access? Yes NO Already Signed Up Parent/Guardian Name: DOB: / / Please list other siblings you would like to add: Name: DOB: Name: DOB: Name: DOB:
Medical Information Release Form (HIPPA Release Form) Name: Date of Birth: / / Release of Information [ [ I authorize the release of information, including the diagnosis, records, examination rendered to me and claims information. This information may be released to: [ [ Spouse [ ] Child(ren) [ ] Other [ ] Information is not to be released to anyone. This release of information will remain in effect until terminated by me in writing. Messages Please call [ ] my home [ ] my work [ ] my cell If unable to reach me: [ ] you may leave a detailed message [ ] please leave a message asking me to return your call [ ] other. The best time to reach me is (day) between (time). Sign: Date: / / Witness: Date: / /
HIPPA Acknowledgement and Consent Form I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up care amoung the multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from designated third party payers. Conduct normal health care operations such as quality assessments or evaluations and physician certification. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in the office in print form). I have reviewed such Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices. I understand the organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is abound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. Patient s Name (print) Signature (Patient or Legal Representative) / / Date of Birth - - Date Legal Representative s Relationship to Patient