Health Solutions Medical Center - Patient Information Form

New Patient Paperwork
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
At which location would you prefer to receive your services?
What type of healthcare service are you interested in?
Patient Name

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

First NameMiddle Name/InitialLast NameSuffix
How did you hear about us?
Pronouns

Other
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?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone
Format: (000) 000-0000.
Ok to Contact Emergency Contact Phone
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.Format: (000) 000-0000.
Parent/Guardian Mobile Number
Format: (000) 000-0000.
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.Format: (000) 000-0000.
2nd Parent/Guardian Mobile Number
Format: (000) 000-0000.
Other Patient Information
Birth Sex
Current Sex
Marital Status
Racial category most closely identifies with:
Ethnicity
Language preference:

Other
Primary Role
Place of Residence

Other
Current living arrangement
Number of Dependents?
Highest Level of Education?
Legal Status?
Are you a Veteran?
Are you pregnant?
Are you disabled?
Do you need transportation?
How may we contact you? (Please select all that apply)
Confidentiality
Would you like to receive notifications?
Advanced Directive
Do you have a Living Will/Do not resuscitate order?
Do you have a Durable Power of Attorney?
If yes above, please provide name and phone number:
Would you like information regarding Advance Directive?
Medical History
Please check all that apply to you and add notes below as needed.

Other
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)
List allergy Information here:
Have you had any previous hospitalizations? (Include non-surgical hospitalizations.)
Previous Hospitalizations
Have you had any previous surgeries? (Include all surgeries in your lifetime)
Surgery History
Family Medical History

Please check all conditions that apply to each family member:

Rows	Alive	Deceased	No Known Allergies	Alcohol Abuse	Asthma	Blood Clots	Breast Cancer	Colon Cancer	Prostate Cancer	Other Cancer	Dementia	Diabetes	Heart Disease	High Blood Pressure	High Cholesterol	Kidney Disease	Liver Disease	Lung Disease	Mental Illness	Ovarian Cancer	Stroke	Thyroid Condition	Other
Mother
Father
Sister
Brother
Son
Daughter
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Are you currently taking any medications?
List of Medications Currently Using:
OB/GYN HISTORY
Number of Pregnancies
Number of Deliveries
Last Menstrual Cycle

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you currently use tobacco? (Includes cigarettes, cigars, eCigarettes, and smokeless tobacco)
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?
Do you currently drink alcohol regularly?
If yes, approximately how many drinks per week (beer, wine, liquor)?
Substance History
If yes, what types?
Approximately how many times per week?
Alcohol Abuse?
Type of Alcohol:
How Often:
Sexually Active?
Partner(s)
Type of Birth Control / Protection
Diet (Check all that apply)

Other
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)

Other
Do you feel safe at home?
Family Medical History
Is there a Family Medical History of the following?:
Heart Attack
List Relatives Affected by Heart Attack:
Diabetes
List Relatives Affected by Diabetes:
Prostate Cancer
List Relatives Affected by Prostate Cancer:
Kidney Cancer
List Relatives Affected by Kidney Cancer:
Kidney Stones
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

Family 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?: