Fillable Female Male Transgender Female to Male Transgender Male (Pinnacle Medical Group)

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Female Male Transgender Female to Male Transgender Male (Pinnacle Medical Group)

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PATIENT REGISTRATION FORM (eCW)
PATIENT INFORMATION
(Please print)
Patient’s Legal Name: (Last)___________________________________ (First)________________________________ (MI) __________
Preferred Full Name (if different from above): ________________________________
Home Phone Number (landline):__________________________ Cell:_________________________ Work: _______________________
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Email Address:____________________________________________________________________ Date of Birth: ___________________
Gender Identity:
Female Male Transgender Female to Male Transgender Male to Female Genderqueer
Choose not to disclose Additional Gender Category not listed ________________________________________
Race:
American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White
Hispanic Choose not to disclose Other not listed __________________________
Ethnicity:
Hispanic or Latino Not Hispanic or Latino Choose not to disclose
Preferred Language:
English Spanish ASL Japanese Mandarin Korean French Swahili Portuguese Arabic
Indian: Hindi, Tamil, Gujarati etc Russian Vietnamese Haitian Albanian Burmese Cambodian
Creole Bosnian/Croatian/Serbian/Serbo-Croatian Tagalog Farsi-Iranian/Persian Other not listed_____________
Patient Social Security Number:______-______-_______
RESPONSIBLE PARTY INFORMATION (If not self)
(Information used for patient balance statements)
Responsible Party:
Another Patient Guarantor Self Check here is address and telephone information is same as patient
Responsible Party Name: (Last)___________________________________ (First)________________________________ (MI) _______
Date of Birth: MM_____/ DD_____/ YYYY_________ Sex:
Female Male
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Responsible Party Social Security Number:______-______-_______ Phone Number:_____________________________
INSURANCE INFORMATION: Provide your insurance card(s) (primary, secondary, etc.) to the front desk at check-in.
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: (Last)_________________________________ (First)_____________________________________________
Phone Number:________________________________________________ Do you have a living will: Yes No
Emergency contact relationship to patient: _______________________________________________________________
Guardian
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Home Phone:______________________________________________ Work Phone:_______________________________ Ext.________
GENERAL CONSENT FOR CARE AND TREATMENT CONSENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to
be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.
At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the
evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are
indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you
consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have
any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician,
and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed
necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this
practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent
forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Signature of patient or personal representative:___________________________________________________Date:__________________
Printed name of patient or personal representative:__________________________________ Relationship to patient: _________________
Last Updated: May 2018
Patient Name:________________________________________ Date of Birth__________________
Reason for Today’s Visit?____________________________________________________________
PAST MEDICAL HISTORY:
Please list any previous illness, hospitalizations or surgeries, and the year:
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
4. _____________________________________________________________________________________
5. _____________________________________________________________________________________
6. _____________________________________________________________________________________
7. _____________________________________________________________________________________
ALLERGIES Do you have allergies to drugs, food, latex, dye? YES NO
Allergy - list medication, food, latex, dye, etc.
Reaction - rash, shortness of breath, hives, itching,
etc
Have you seen a cardiologist in the past? Yes No
If yes: Cardiologies Name:___________________________ Location:_________________________________
Have you been told you have any of the following (Circle all that apply and enter approx. date of first diagnosis):
Angina _________________; Mitral Valve Prolaps _________________; Heart Murmur __________________;
TIA ____________________; Diabetes ___________________________; High Blood Pressure _____________;
Heart Attack _________________
Have you ever had any of the following procedures? If yes, please indicate when:
Heart Catheterization____________________________; Exercise Test ________________________________;
Angioplasty ___________________________________; Holter Monitor_______________________________;
Coronary Bypass _______________________________; Echocardiogram______________________________;
2
Rev: 7/19
Patient Name:________________________________________ Date of Birth__________________
FAMILY HISTORY
Living
Age Health Status
Father
Mother
Sisters
Brothers
Deceased
Age at Death Cause of Death
Father
Mother
Sisters
Brothers
Do you have a Family History of?
Diabetes High Cholesterol Stroke Cancer Heart Attack
Social History
Are you: Married Single Divorced Widowed
Number of Children? ______________________ Ages __________________________________________
Do you smoke? Yes ____ No ____ How much ______ How Long ______ Year Quit ____________
Do you drink alcohol? Yes ____ No _____ how much per week? _________________________________
Do you exercise? Yes ____ No _____What do you do? ___________________Frequency__________
Please circle if it applies to you:
Eyesight:
Ears, Nose, Throat:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Neurological/Psychiatry:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Good - Fair - Poor - Glaucoma
Poor Hearing - Sore Throat - Sinus Problems
Swallowing Problems - Indigestion - Ulcers Hiatal Hernia - Bloody stools - Diarrhea
Difficulty Urinating - Blood in Urine - Prostate Problems - Kidney problems – Postmeno.
Muscle Pain - Joint pain - Arthritis
Skin Rash - Skin Disorders
Fainting - Depression - Anxiety - Drug Dependence
Thyroid Disease - Diabetes
Taking Blood Thinners - Taking Aspirin - Coumadin
Sinusitis - Hayfever - Allergies
*Please answer the questions in the following sections, if they apply to you*
3
Rev. 7/19
Patient Name:________________________________________ Date of Birth__________________
Chest Pain
Do you have Chest Pain? Yes _____ No _____ If yes answer questions 1-9. If NO move to the next section.
1. How long have you had chest pain? __________________________________________________
2. Location of chest pain? ____________________________________________________________
3. Radiation of chest pain: none, left arm, left shoulder, right arm, right shoulder, jaw, back (circle)
4. Character of pain: dull, pressure, heaviness, sharp (circle)
5. Duration of episodes: seconds, minutes, hours, constant (circle)
6. Severity of pain 0-10 (zero being pain free) _________
7. Do you have pain with: exercise, resting or both? (circle)
8. Do you have any of the following with your pain? shortness of breath, nausea, palpitations or sweating
Peripheral Arterial Disease
1. When you walk or exercise, do you experience discomfort (aching, cramping or pain) Yes/No
A. If you answered yes, does the discomfort subside with rest? Yes/No
2. Have you ever had surgery, balloon procedures, or stents to any blood vessels other than your heart? Yes /No
3. Do you have painful sores or ulcers on your legs or feet that are not healing? Yes/No
4. Are your toes or feet pale, discolored, or bluish? Yes/No
5. Have you ever been told by a physician that you have poor circulation? Yes/No
Shortness of Breath
Do you have shortness of breath? yes ____ no ____ If yes answer questions 1-9. If no move to the next section.
1. How long have you had shortness of breath? _____________________________________________
2. What makes you short of breath? ______________________________________________________
3. Do you wake up at night short of breath? never, rarely, every night (circle)
4. Do you get up to urinate at night? yes ____ no ____
5. Do you tire easily? yes ____ no ____
6. Do you have leg or ankle swelling? yes ____ no ____
7. Do you have wheezing? yes ____ no ____
8. Do you have
a cough? yes ____ no ____ Sputum production? yes ____ no ____
Palpitations
Do you have palpitations? yes ____ no ____ If yes answer questions 1-5. If no move to the next section.
1. How long have you had palpitations? __________________________________________________
2. Does your heart feel like: skipping beats, racing, beating fast & regular, beating fast & irregular? (circle)
3. Do your palpitations occur with any of the following: rest, exercise, excitement, alcohol, caffeine? (circle)
4. Are you under a lot of tension and stress? yes ____ no ____
5. Do you have other symptoms with your palpitations? none, dizziness, fainting, shortness of breath, nausea,
sweating, lightheadedness (circle)
Patient Signature: ______________________________________ Date: _______________________
PHYSICIAN SIGNATURE: __________________________________________________________
4
Rev: 7/19
Medication Chart
Help us care for you better by telling us what prescriptions and over-the-counter medications you take.
Update us every time you visit.
Prescriptions
Name of
medicine
Dose
(total
milligr
ams)
How
many
times
per
day?
When do
take it?
(Morning
and night?
After
meals?)
Who prescribed
it for you?
(Physician’s last
name)
Why do
you take
it?
Do have any side-effects?
Describe them.
Over-the-counter medications, herbal remedies, vitamins
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Female Male Transgender Female to Male Transgender Male (Pinnacle Medical Group)

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Completed 1 March 2021

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