Patient Registration Information Form
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2Patient Registration Information
Doctor:
Location:
Chart#
Name:
Sex:
M
F Date of Birth:
Social Security #:
Email:
Street Address:
City:
State:
Zip Code:
County:
Phone Numbers: Home:
Work:
Cell:
Preferred Method of Contact:
Email
Mail
Phone: check preferred phone
Home
Work
Cell
Marital Status:
Single
Married
Divorced
Widowed Race:
Language:________________________ Employment Status:
Employed
Unemployed
Retired
Student
School / Employer’s Name:
School / Employer’s Address:
Spouse’s Name:
Date of Birth:____________________________
Social Security #:
Employer’s Name:_________________________________
Employer’s Address:_____________________________________ Work Number:________________________
Emergency Contact/Relationship:________________________________________________________________
Phone Numbers: Home:
Work:
Cell:
Reason for Visit:_____________________________________ Date of Occurrence:_______________________
Have you been treated for this problem before?
Yes
No
Have you been treated elsewhere?
Yes
No
If yes, where and by whom?____________________________________________________________________
Did you have any injury?
Yes
No
If yes, was it?
At work?
Yes
No
In a motor vehicle accident?
Yes
No
Other type of injury? ________________________________
Date of injury? _____________________________________
Litigation Pending?
Yes
No
Was Onset:
Gradual or
Sudden Answer:________________________________________________
Never smoker
Current every day smoker
Current some day smoker
Heavy
Smoking Status:
Tobacco smoker
Light tobacco smoker
Smoker, current status unknown
Unknown if ever smoked
Former Smoker
Enter additional Information needed if smoker or former smoker:
Date patient started smoking or using tobacco: __________________ Packs per day: _______________
Date patient quit smoking or using tobacco: __________________
Do you drink alcoholic beverages?
Yes
No
If yes, please list amount and frequency: _______________
Do you use recreational drugs?
Yes
No
If yes, please list type and frequency: _____________________
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Parent category: Medical