Patient Information Form
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1CHICAGO HEALTH MEDICAL GROUP
PATIENT INFORMATION
__________________
TODAY’S DATE:
PATIENT NAME: _________________________________________________
DATE OF BIRTH: _________ AGE: _____
MALE ___
FEMALE ___
(FIRST)
(LAST)
(MIDDLE INT)
MARITAL STATUS:
___ SINGLE
ADDRESS: ______________________________________________________
___ MARRIED
___ OTHER (WIDOW, DIVORCE, SEPARTED)
________________________________________________________________
CITY)
(STATE)
(ZIP CODE)
RACE: (check one)
__American Indian/Alaska Native
__Middle Eastern/North African
SS#: ___________________________________________________________
__Asian/Oriental
__White
__Black/African American
__Other ___________________
HOME PHONE: __________________________________________________
ETHNICITY: (check one)
__Central American
__Mexican
CELL PHONE: ___________________________________________________
__Cuban
__Not Hispanic or Latino
__Dominican
__Puerto Rican
WORK PHONE: ________________________________ EXT: ____________
__Hispanic/Latino/Spanish
__South American
__Latin American
__Spaniard
CONTACT PREFERENCE:
__Other ___________________
___Home Phone
___Cell/Mobile
___Work Phone
___Mail
EMAIL: _________________________________________________________
IS INJURY RELATED TO: (check one)
PRIMARY CARE PHYSICIAN: _______________________________________
WORK ______
AUTO ACCIDENT ______
OTHER ______
EMPLOYER: ____________________________________________________
DATE OF INJURY: ________________________________________
EMPLOYER ADDRESS: ___________________________________________
LAST DAY WORKED: _____________________________________
________________________________________________________________
(CITY)
(STATE)
(ZIP CODE)
SPOUSE’S NAME: ___________________________________________SPOUSE WORK PHONE: ____________________________ EXT: ________
EMERGENCY CONTACT: _____________________________________(Relationship):__________________
___________________________________
(NAME)
(PHONE - DIFFERENT FROM ABOVE)
DO YOU HAVE AN ADVANCE DIRECTIVE? (LIVING WILL/POWER OF ATTORNEY)
yes___
no___ If yes, please provide for our records.
ADVANCE DIRECTIVE INFORMATION PROVIDED _____________
PATIENTS RIGHTS AND RESPONSIBILITIES PROVIDED _____________
OFFICE STAFF INITIALS
OFFICE STAFF INITIALS
POLICY HOLDER INFORMATION
(Please complete, if different from patient information)
POLICY HOLDER NAME
OR WORKMAN’S COMP: _______________________________________________________ DATE OF BIRTH: __________________
AGE: _______
(FIRST)
(LAST)
(MIDDLE INT)
ADDRESS: _______________________________________________________
MALE _______
FEMALE _______
______________________________________________________________
RELATIONSHIP TO PATIENT:
____
(CITY)
(STATE)
(ZIP CODE)
___ SPOUSE
___ PARENT/GUARDIAN
___ OTHER
EMPLOYER: ______________________________________________________
SS#: ____________________________________________________
EMPLOYER
ADDRESS: _______________________________________________________
HOME PHONE: ___________________________________________
__________________________________________________________________
WORK PHONE: ____________________________ EXT: _________
(CITY)
(STATE)
(ZIP CODE)
W/C Claim #_______________________ Case Manager/Adjuster_______________________ Phone_________________________
CONSENT FOR TREATMENT AND AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize the physician at Chicago Health Medical Group, the nurses, and staff, under their direction, to conduct such
examinations, administer treatment and medications, as they deem necessary or advisable. I hereby authorize the release of any
information acquired by this facility during the course of my examination and/or treatment to my employer, prospective employer,
and/or insurance carrier as required.
_____________________________
_____________________________________________________________________________________________
DATE
SIGNATURE OF PATIENT/GUARDIAN
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