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3975735-353695__ Aceves__ Clothier__ Ozaeta__ Oltmann__ Nurse Only00__ Aceves__ Clothier__ Ozaeta__ Oltmann__ Nurse Only4894580-308610__ No Pref__ Pt ReqMRN_______________________00__ No Pref__ Pt ReqMRN_______________________553720-19050Dignity Health Medical GroupSaint Francis/ St. Mary’sA service of Dignity Health Medical Foundation00Dignity Health Medical GroupSaint Francis/ St. Mary’sA service of Dignity Health Medical Foundation NameLast: First: Middle:Sex: CIRCLE ONEFemale MaleDate of Birth: / / Social Security Number:Home Address:Street:City: State: ZIP:Mailing Address: (If different than home)Street:City: State: Zip:Phone: ( ) _ _ _- _ _ _ _Cell Phone: ( ) _ _ _- _ _ _ _Marital Status: Circle OneSingle Married Divorced WidowPrevious Last Name:Race: __ African American __ American Indian/Alaska Native __ Asian __ Native Hawaiian / Other Pacific Islander__White __ Other __ Declined to StateEthnicity: __ Hispanic, Latino, or Spanish Origin __ Not Hispanic, Latino, or Spanish Origin __ Declined to StateLanguage:Emergency Contact: Name: Relationship: Phone: ( ) _ _ _- _ _ _ _USF Student ID number:Insurance Name and Address:Insurance Phone # ( ) _ _ _ - _ _ _ _Policy Number (Certificate #, Member #, ID # )Alfa prefix (if any) _ _ _ _ _ _ _ _ _ _ _ _ Suffix (if any) _ _ _Group # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Subscriber Name and DOB:Circle One: Self/Spouse/Child/ Other: Name:DOB: / /IF A MINOR, PERSON RESPONSIBLE FOR PAYMENT OF BILLName: Last First MiddleDOB:Address:Phone: ( ) _ _ _- _ _ _ _ Social Security Number: _ _ _- _ _- _ _ _ _Signature: Date: / /-42545221615Please describe how you heard about us: USF Mail Cards Internet Friend/Family Insurance Other ____________________________________________________________________________________________________________00Please describe how you heard about us: USF Mail Cards Internet Friend/Family Insurance Other ____________________________________________________________________________________________________________Dignity Health Medical Group Saint Francis/St. Mary’s A service of Dignity Health Medical FoundationPortal Registration ConsentName:___________________________________Patient Name (if different)_________________292417513970008667754381500Relationship: Self Primary Custodian (Primary Account Holder)292417543180008667754318000 Dependent Child *Custodian (Read Only Access)8667752540000 Foster Child *Note: There can only be one primary custodian peraccountPatient’s DOB: ______________________Email: ________________________________________Dignity Health Provider 1:______________________________Dignity Health Provider 2:______________________________Dignity Health Provider 3:______________________________I AGREE the email address given above is my personal email address to receive my PIN for access to the Dignity Health Online Patient Center. If I am not the patient, I certify that as a patient representative I am authorized to request this account be created for the patient named above.Signature: ______________________________________ Date: __________________________OFFICE USE ONLYI have verified by photo ID, this is the patient/Parent/Guardian.Staff Name: ____________________________________ Date: __________________________________I have completed the initial patient registration.Staff Name: ____________________________________ Date: __________________________________Dignity Health Medical GroupSaint Francis/ St. Mary’sA service of Dignity Health Medical FoundationCONFIDENTIAL HEALTH HISTORYName: ____________________________________________________________________________ Today’s Date: ___________________Age: _______ Date of Birth: __________ Date of last physical examination: _________________What is the reason for today’s visit? ____________________________________________________________________________________ILLNESSES: Please indicate if you now have or had any of the following illnesses and the year that the condition began.ALLERGIESEMPHYSEMAPROSTATEANEMIAEPILEPSY/ SEIZURESPSYCHIATRICARTHRITISGOUTSINUS PROBLEMSASTHMAHEADACHESKIN DISEASEBACK PROBLEMSHEART DISEASESTROKEBLEEDING DISORDERHEPATITISTHYROID DISEASEBRONCHITISHIGH BLOOD PRESSURETUBERCULOSISCANCER HIGH CHOLESTEROLULCERSBREASTKIDNEY DISEASEVASCULAR DISEASE/COLONLIVER DISEASECIRCULATIONCATARACTSMIGRAINEVENERAL DISEASEDEPRESSIONMULTIPLE SCLEROSIS(HERPES, HPV, ETC.)DIABETESPNEUMONIAVISION PROBLEMSOther significant illnesses not listed above: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any abnormal tests (blood, x-ray, etc): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SURGERIES/HOSPITALIZATIONS: Please indicate if you had any of the following surgeries and indicate the year the surgery occurred. APPENDIXCATARACT SURGERYKIDNEY/ BLADDERBREAST BIOPSYCOLON/RECTAL SURGERYTONSILSBREAST MASTECTOMYD & CTUBAL LIGATIONC-SECTIONGALLBLADDERTUBES IN EARSCARDIAC SURGERYHYSTERECTOMY VASECTOMYPlease list any other significant surgeries (back, knee, hip, shoulder, thyroid, etc): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ARE YOU CURRENTLY ON ANY MEDICATIONS? If YES, list medications and dosages below: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ALLERGIES TO MEDICATIONS: Please describe your allergic reaction(s)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 1 of 2CONFIDENTIAL HEALTH HISTORYIMMUNIZATIONS AND PREVENTION: Please indicate if you had any of the following immunizations/test(s) and the last date of service.__ Tetanus_________________ TB Skin test_________________ PAP Smear_________________ Influenza vaccine_________________ Hearing Test_________________ Mammogram_________________ Pneumonia vaccine_________________ Eye Exam_________________ Bone Density_________________ Colon Cancer_________________ Cholesterol_________________ PSA Test_______________FAMILY HISTORYLiving DeceasedAgeChronic Health Problems/Cause of DeathFather_______________________________________________________ _________________Mother_________________________________________________________ _______________Brothers (B) (# ____)___________________________________________________________ _____________Sisters (S) (# ____)_____________________________________________________________ ___________B or S_______________________________________________________________ _________B or S_________________________________________________________________ _______Spouse___________________________________________________________________ _____Children (#____)_____________________________________________________________________ ___Have any relatives suffered from any of the following, if yes; please list the relatives that were/was affected:WHO?WHO?__ Bleeding problems___________________________ High Blood Pressure___________________________Cancer, breast___________________________ Kidney Disease___________________________ Cancer, colon___________________________ Liver Disease___________________________ Cancer ________________________________________ Mental Illness___________________________ Diabetes___________________________ Seizures___________________________ Glaucoma___________________________ Stroke___________________________ Heart Disease___________________________Thyroid___________________________ Other ___________________________________________ Other_________________________SOCIAL AND PERSONAL HISTORYAnswering these confidential questions honestly will allow an accurate assessment of your health risk(s). If you are uncomfortable with any question you have the option to leave it blank. Current Occupation: _________________________________________________________________________________________________Education Completed: _______________________________________________________________________________________________Marital Status: __ Single __ Married (Year: ___) __Widowed (Year: ____) __ Separated (Year: ___) __Divorced (Year: ___) Married __ time(s) 1st Marriage __ year (s) ___number of children 2nd ___yrs ___children 3rd ___yrs ___childrenI live with: ___________________________________________________________________________________________________________ Current tobacco use: Type: __ Cigarette Cigar __Pipe __ Chew Amount/Day: ___ ____ Years: _______ Former tobacco use: Type: __ Cigarette Cigar __Pipe __ Chew Amount/day: ________ Years: _____ Quit Date: ___ Exposure to second hand smoke__ Consume alcohol Type: _______________ How Much? __________ How Often? ______________ (per day/week)__ Use recreational drugs Type: _______________ How Much? __________ How Often? ______________ (per day/week)__ Consume caffeine Type: _______________ How Much? __________ How Often? ______________ (per day/week)__ Exercise regularly Type: _____________________________________ How Often? ______________ (per day/week)__ Use sunscreen __Take calcium supplements Do you wear your seatbelt? __________ Have you had a blood transfusions? Year: ________________ Do you have tattoos? ______ Sexual History: Are you sexually active? __Yes __No __Not currently My sexual partner(s) is/are: __male __femalewas/were: __male __female History of sexually transmitted diseases? __ Yes __No __ Use contraception Type: ___________ Staff Name: ____________________________________ Date: __________________________________ ................
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