Demographic Information Form

PrimaryPlus Information Form                                                    

Medical Record#________________ 

(office use only) 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:__________________________________________________________     _____________________ 

                          Last                                                                First                                                          Middle                                                 Maiden 

Preferred Name: ________________________________     Social Security: _______ ‐ ______ ‐__________ 

 

DOB: ______________________     Preferred Provider/Clinician:__________________________________        

                                                                                                (This is the provider that you primarily want to see and to manage your overall care) 

Preferred Pharmacy: ______________________________________________________________________ 

 

Your  Address:___________________________________________________________________________ 

                                                  Street                                                                                                              City                                                           State/Zip Code 

Do you speak and understand English?    Yes       No        

               Gender:   M   /    F 

Marital Status: (circle one)          Single        Married        Divorced        Widowed       Separated 

Race:     White     Black      Asian      American/Indian                     Ethnicity:    Hispanic          Non‐Hispanic 

 (If biracial, circle the race you most identify as) 

Contact Information:    

 

 

 

 

 

Is it OK to leave a message?                              

                                  

 

(circle the method below you prefer to be contacted at)

Home Phone:__________________________________ 

 

 

YES 

 

NO 

 

 

Cell Phone:____________________________________ 

 

 

YES 

 

NO 

Work Phone:___________________________________   

 

YES 

 

NO 

Email Address:______________________________________________ 

Employer:______________________________________    Occupation:____________________________ 

Veteran Status:      Veteran              Non‐Veteran              

Education Level:   High School      Associates      Bachelor’s     Master’s     Doctorate     Less than High School 

Agricultural Work Status:   Non‐Agricultural   Employed Year‐Around    Seasonal   Migrant     Retired Farmer

  

Housing Status:  Do you consider yourself homeless?   

YES 

 

NO 

Insurance:  ______Private Insurance   ______Medicare  ______Medicaid  ______Self Pay/No Insurance 

Primary Insurance: 

Insured/ Spouse Information 

Name:____________________________ Relation:___________________ Phone:_____________________ 

 

Birth Date:_________________________               Social Security:_________‐ __________‐ _____________ 

 

Please complete the back of this form