Health Solutions Medical Center - Patient Information Form

New Patient Paperwork
Today's Date

MonthDayYear
Date
Patient Name*

First NameMiddle Name/InitialLast NameSuffix
Preferred Name (if different from above)

First NameMiddle Name/InitialLast NameSuffix
Pronouns

He/His/HimShe/Hers/HerOther
Patient DOB*

MonthDayYear
Client Age
SSN
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Mailing Address different that Physical Address from above?*

NoYes
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone
Ok to Contact Emergency Contact Phone

Check if OK to contact in an emergency?
Preferred Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Primary Insurance
Member ID
Subscriber Name

First NameLast Name
Subscriber DOB

MonthDayYear
Subscriber SSN
Secondary Insurance
Member ID
Subscriber Name

First NameLast Name
Subscriber DOB

MonthDayYear
SSN
Parent/Guardianship Section
If patient is under 18 years old, please enter parent/guardian information. Anyone other than parent(s) must provide proper documentation.
Parent/Guardian Name

First NameMiddle Name/InitialLast NameSuffix
Parent/Guardian DOB

MonthDayYear
Parent/Guardian SSN
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Mobile Number
2nd Parent/Guardian Name

First NameMiddle Name/InitialLast NameSuffix
2nd Parent/Guardian DOB

MonthDayYear
2nd Parent/Guardian SSN
2nd Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent/Guardian Phone Number
Please enter a valid phone number.
2nd Parent/Guardian Mobile Number
Other Patient Information
Birth Sex*

MaleFemale
Current Sex*

MaleFemale
Marital Status*

MarriedDivorcedSeparatedDomestic PartnershipSingle/Never Married
Racial category most closely identifies with:*

DeclineAfrican AmericanAsianCaucasianHispanicNative AmericanNative HawaiianPacific Islander
Ethnicity*

DeclineHispanic or LatinoNot Hispanic or Latino
Language preference:*

EnglishSpanishOther
Primary Role*

StudentMilitaryRetiredVolunteerHomemakerEmployed Full Time (35+ hours/wk)Employed Part Time (Under 35 hours/wk)Unemployed
Place of Residence*

Independent LivingAssisted LivingSupported HousingBoarding Home/Adult ResidentialNursing HomeFoster HomeHalfway HouseHomelessSober LivingOther
Current living arrangement*

AloneSpousePartner/Significant OtherChildrenFatherMotherFoster Parent(s)GuardianRelative(s)Sibling(s)Unrelated Person
Are you a Veteran?*

NoYes
Are you pregnant?

NoYes
Are you disabled?*

NoYes
Do you need transportation?*

NoYes
How did you hear about us?
How may we contact you? (Please select all that apply)

Home PhoneCell PhoneSMS/TextingEmailPatient Portal
Confidentiality

Do not call home phoneDo not call cell phoneDo not leave message
Would you like to receive notifications?*

VoicemailSMS/TextEmailOpt Out
Advanced Directive
Do you have a Living Will/Do not resuscitate order?*

NoYes
Do you have a Durable Power of Attorney?*

NoYes
If yes above, please provide name and phone number:
Would you like information regarding Advance Directive?*

NoYes
Medical History
Please check all that apply to you and add notes below as needed.*

No Medical HistoryAIDSAllergies (see p.4)AnemiaAngina (Heart Pain)Arrhythmia / PalpitationsArthritisAsthmaAtrial FibrillationBleeding DisorderBlood ClotBlood TransfusionBone LossCataractsChronic FatigueChronic Kidney DisorderCOPD / EmphysemaCVA / StrokeDiabetes – Type:Dialysis – Type:Disability – Type:DiverticulitisEar Infection, recurrentFibromyalgiaGenetic/Congenital ConditionGERD (Heartburn)GI BleedGlaucomaGunshot WoundHead Injury / ConcussionHearing LossHeart DiseaseHeart FailureHepatitis – Type:HIVHigh CholesterolHigh Blood PressureIrritable Bower SyndromeKidney StoneLong-term Steroid UseLupusMacular DegenerationMI (Heart Attack) Date:Motor Vehicle AccidentOxygen UsePeripheral Artery DiseasePneumoniaRestless Leg SyndromeRheumatoid ArthritisSciaticaScoliosisSeasonal AllergiesSeizuresSinusitis, recurrentSleep ApneaThyroid DisorderTuberculosisUTI (Bladder Infection)VertigoOther
If any notes or clarification are needed for above, please type them in here:
Do you have Allergies? (Include medications, foods, environmental, x-ray dyes, etc. Add extra sheet if necessary)*

None KnownYes
List allergy Information here:
Have you had any previous hospitalizations? (Include non-surgical hospitalizations.)*

NoYes
Previous Hospitalizations
Have you had any previous surgeries? (Include all surgeries in your lifetime)*

NoYes
Surgery History
Are you currently taking any medications?*

NoYes
List of Medications Currently Using:
OB/GYN HISTORY
Number of Pregnancies
Number of Deliveries
Last Menstrual Cycle

MonthDayYear
Date
Do you currently use tobacco? (Includes cigarettes, cigars, eCigarettes, and smokeless tobacco)*

Never UsedNoYes
If Yes above, I use(d) tobacco an average of:*
If you have quit tobacco, what year did you quit?
Have you ever been diagnosed with Alcoholism?*

NoYes
Do you currently drink alcohol regularly?*

NeverRarelyYes
If yes, approximately how many drinks per week (beer, wine, liquor)?
Substance History*

NoNeverRarelyYes
If yes, what types?
Approximately how many times per week?
Sexually Active?*

NeverNot CurrentlyYes
Partner(s)

Male Partner(s)Female Partner(s)
Type of Birth Control / Protection
Diet (Check all that apply)*

Well-balancedDiabeticExcessive CaloriesVegetarianVitamin(s)/Herbal(s)Routine MealtimesOther
Caffeine: How much per day?*
Other
Exercise (Activity that causes light to heavy sweat)
How many days/week do you engage in moderate to strenuous activity?*
How many minutes per day on average?*
SAFETY (Check all measures you are currently using)*

CO Detector in homeGuns Unloaded/LockedHelmet UseSeat Belt UseSunscreen UseWater Temperature SetNone of the AboveOther
Do you feel safe at home?*

NoYes
Family Medical History
Is there a Family Medical History of the following?:
Heart Attack*

NoYes
List Relatives Affected by Heart Attack:
Diabetes*

NoYes
List Relatives Affected by Diabetes:
Prostate Cancer*

NoYes
List Relatives Affected by Prostate Cancer:
Kidney Cancer*

NoYes
List Relatives Affected by Kidney Cancer:
Kidney Stones*

NoYes
List Relatives Affected by Kidney Stones:
Please list or describe any other significant disease in your family's medical history that we should be aware of:
Please include Paternal/Maternal/Sibling information.
Should be Empty:

New Patient Paperwork

Insurance Information

Parent/Guardianship Section

Other Patient Information

Advanced Directive

Medical History

OB/GYN HISTORY

Exercise (Activity that causes light to heavy sweat)

Family Medical History

Is there a Family Medical History of the following?: