PATIENT REGISTRATION FORM - Family Allergist
PATIENT REGISTRATION FORM
First ______________________________ MI________ Last__________________________________ Pt.ID #________________
Prefers to be called_______________ Date of Birth ____/_____/______ Age ____ Marital Status: ____________________________ Married/ Single/Divorced/Widowed/Other
Address Primary _______________________________ City _______________________________ State_____ Zip _____________
Alternate Address ______________________________ City ________________________________ State_____ Zip ____________
Phone #1 _________________________ Home/Cell/ Work
Phone #2 ________________________ Home/Cell/ Work
Phone #3 _____________________ Home/Cell/ Work
Email address __________________________ Preferred method of contact: Letter Phone call Email Other______________
Sex____ SS # ___________________Referring Physician _______________________Primary Care Physician__________________ M F
Preferred Language ___________ Race: _________Ethnicity: _______________________________________________________ Non-Hispanic or Latino/ Hispanic or Latino/ other or Undetermined
Referred by: Physician Self Family/Friend Internet Yellow pages Radio TV Other ____________________________
Occupation_________________________Employer___________________________Is this visit related to a work injury? Y N
Current Pharmacy Name and Location ____________________________________________________________________________
Emergency Contact Name _______________________ Phone # ______________________ Relationship to patient______________
Responsible Party/Guardian/Guarantor
Address Same as Patient
Name__________________________ Address______________________ ______ City________________ State ___ __Zip________
Home# ________________________ Cell # ________________________________ Business # _________________________
SS#___________________________ Patient's Relationship to Guarantor________________________ DOB ____/____/____ ____
Sex _______ Occupation_________________________________ Employer _____________________________________________
Primary Insurance Information
Address Same as Patient
Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________
Policy Holder Name ______________________________DOB ____/____/______Relationship to Patient _____________ _________
Address_______________________ ___ City________________ State_____ Zip________ Phone #___________________________
SS# ______________________ Sex______ Occupation_____________________ Employer _________________________________
Secondary Insurance Information
Address Same as Patient
Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________
Policy Holder Name ______________________________ DOB ____/____/_______Relationship to Patient_____________________
Address____________________________City________________ State. ______Zip_______Phone# __________________________
SS# _______________________Sex_____Occupation____________________Employer____________________________________
Financial Authorization
We participate and accept assignment of payment with most major insurance plans in the area. Even though we may submit insurance claims for you, your insurance coverage is a contract between you and your insurer and you are still responsible for payments and services regardless of the amount your insurance pays. If your insurance company requires an authorization or referral, it is the patient's responsibility to obtain this for the initial visit and for continuation of care.
I hereby authorize the office of Allergy Partners, P.A .to release any information necessary to process any insurance claim for services rendered. I hereby authorize payment from my insurance company or governmental payor to pay directly to Allergy Partners, P.A. for services rendered. Regardless of my insurance benefits, if any, I understand that I am financially responsible for the fees for services rendered.
Print Name/Signature ___________________________________________________________________Date_______________
Print Name / Signature
Patient/Parent/Guardian
1
ACKNOWLEDGEMENT ACKNOWLEDGEMENT OF HIPAA PRIVACY NOTICE AND DESIGNATION OF DISCLOSURE
Patient Name:___________________________________
Date of Birth:____________________
Notice of Privacy Practices. I acknowledge that I have received the practice's Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint.
______________________________________________________________________________________ Date_______________
Print Name
/
Signature Patient/Parent/Guardian
Communication/Messages: I understand that it may be necessary from time to time for Allergy Partners to leave messages when
we are unable to reach you. I wish to be contacted as follows: (please designate preferred number to call)
YES NO
Home telephone ______________________ Leave message with confirmation of appointment, or call back only.
Leave message with results, detailed information.
Work telephone ______________________ Leave message with confirmation of appointment, or call back only.
Leave message with results, detailed information.
Cell telephone ______________________ Leave message with confirmation of appointment, or call back only.
Leave message with results, detailed information.
Send appointment reminders via text message.
Family Members/Parents/Friends: I authorize Allergy Partners to share my Patient Health Information with the following:
Print Name________________________________________
Relationship________________________
Print Name________________________________________
Relationship________________________
*Patients aged 18 years and older: Please note that we cannot discuss your healthcare, insurance or payment with your parents/others unless you fill out the appropriate information above.
Special requests to identify specific person(s) not authorized to receive my PHI, speak directly with the Practice Manager.
I may revoke my consent in writing by completing a new Acknowledgement of HIPAA Privacy Notice and Designation of Disclosure form except to the extent that the practice has already made disclosure in reliance upon my prior consent.
______________________________________________________________________________________ Date_______________
Print Name
/
Signature Patient/Parent/Guardian
RESEARCH
We perform medical research at Allergy Partners and frequently work with drug companies to help bring new treatments for allergies and asthma to the market. Our clinical researchers may look at your health records as part of your current care or to prepare or perform research. All patient research conducted by us goes through a special process required by law that review protections for
patients involved in research, including privacy.
If you do not object to being contacted about research opportunities by our clinical research team, please select yes: Yes
If you prefer not to be contacted by our clinical research team, you must opt out by selecting no:
No
______________________________________________________________________________________ Date_______________
Print Name
/
Signature Patient/Parent/Guardian
MEDICAL HISTORY FORM
Name:_________________________ Date of Birth:____________
Past Medical History:
( check any of the following which you have now or have been treated for in the past )
ADD
Chronic Pansinusitus
Heart Disease
Alcoholism
Congestive Heart Failure
Hyperlipidemia
Anemia
Connective Tissue Disease Hypertension
Anxiety
COPD
Hypothyroidism
Arthritis
Depression
IBD
Asthma
Diabetes
IBS
Chronic Hives
Eczema
Immune Deficiency
Chronic Rhinitis
Food Allergies
Kidney Disease
Chronic Sinusitis
GERD/Reflux
Liver Disease
Migraines Skin Cancer Other Cancer Prostate Disorder Sleep Apnea
Thyroid Disease
Tuberculosis
Surgery History:
Adenoidectomy Gallbladder (Cholecystectomy) Deviated Septum Hip/Knee Surgery Pacemaker Tonsillectomy
Appendectomy Colon Resection Ear tubes Hysterectomy Sinus Surgery Thyroid Surgery
CABG (heart bypass) C- section Hernia Repair Organ Transplant Tonsillectomy & Adenoidectomy
Other___________________________
Family History: (Immediate family only Mother, Father, Sibling or Children)
Mother No Problems Unknown History Allergies Asthma Anaphylaxis Cystic Fibrosis Eczema Food Allergies Heart Disease Hives Hypertension (high blood pressure) Hyperlipidemia (high cholesterol) Immune Deficiency Recurring Infections Psychiatric Disorder Swelling Venom Allergies
Father
Sibling
Patient's children
Social History (13 years of age and older) marital status: single divorced/separated married widow(er) occupation:______________________________ work location: indoors outdoor alcohol intake never rarely weekly daily socially
Hours of workday spent outdoors: _________ smoking status: current every day smoker current some day smoker former smoker
never smoker unknown if ever smoked cigarettes _____ packs per day cigars _____# per day smokeless/chew _____tins per day smoking duration: n/a 1-5 years 6-10 years 11-20 years over 20 years year started: ______ year quit:______ maximum packs per day: ? 1 1 ? 2 or more readiness to quit: very ready somewhat ready not ready relapsed not willing to quit target quit date:______ quit confidence: not worried about restarting smoking at all somewhat worried about restarting smoking
1
very worried about restarting smoking will definitely restart smoking
Pediatric patients only
attends school daycare stays at home (name of school/daycare) ________________________________
does child have siblings? yes no if yes, how many _____
Extracurricular activities: ______________________________________________________________________
child was born
premature full term
delivery type
vaginal C-section
complicated labor and delivery
yes no
prolonged hospitalization as newborn yes no
breast fed
yes no
feeding difficulties
yes no
severe infections
yes no
LATE on immunizations
yes no
Abnormal growth and development yes no
2
MEDICATION FORM Name:_________________________ Date of Birth:____________
Medication Name
Current Medications and Supplements
(include milligram and number of times per day)
Strength
Times per Day Taking This for What Diagnosis?
Name of Medication
Allergies to Medications Reaction (hives, throat swelling, other reactions)
NO KNOWN DRUG ALLERGIES
When was your last flu shot?_________________________ When was your last pneumonia shot?___________________ Preferred Pharmacy: (Name) ____________________________________________________________________________ (Street Address) _____________________________________________________________________ (City, State, ZIP Code) _______________________________________________________________ (Telephone Number) _________________________________________________________________ (Fax Number) _______________________________________________________________________
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