Fillable PATIENT REGISTRATION INFORMATION FORM (PLEASE PRINT)

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PATIENT REGISTRATION INFORMATION FORM (PLEASE PRINT)

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  • 123 check-boxes
  • 191 other fields

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108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
PATIENT REGISTRATION INFORMATION FORM (PLEASE PRINT)
Name: I prefer to be called:
Date of Birth: Sex: SSN: Marital Status:
Address: City: State: Zip Code:
Cell# Home# Work#
The best time to contact you:
Email Address:
Race:
Referring Provider: Address: Phone:
Primary Care Provider: Address: Phone:
Emergency Contact Name: Relationship: Sex:
Address: Home# Work# Cell#
How did you nd us? Do you have a Health Savings or Flex Account?
EMPLOYMENT INFORMATION
Employer: Employment Status:
F/T P/T or Unemployed
Employer Address: City: State: Zip Code:
PRIMARY INSURANCE INFORMATION
Insurance Name:
Subscriber ID#: Group#:
Subscriber Name: Date of Birth: SSN:
SECONDARY INSURANCE INFORMATION
Patient Relationship to Subscriber: (Please check)
Subscriber ID#: Group#:
Subscriber Name: Date of Birth: SSN:
A.M.
Ethnicity: (Please check) Hispanic Non-Hispanic Unknown
Self Spouse Father Mother Other
Do not wish to provide
P. M . On my: Cell phone Home phone
108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
PATIENT PORTION WAIVER APPLICATION
(i.e. deductibles, co-insurance, etc.)
You may use this form if you believe you have experienced nancial hardship and feel you may qualify for
a waiver of your copayment and/or deductible. You may seek a waiver only for nancial hardship and this
document is considered an attestation of such. You also acknowledge that there are no guarantees, neither
explicit nor implicit, that Viva Eve will grant such a waiver.
Signature of Patient Printed Name Date
FOR OFFICIAL USE ONLY
Please do not mark or write anything below this line.
□ Approved. Comments:
□ Not Approved. Comments:
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signature
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108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
OB/GYN HISTORY FORM
Please take the time to ll out the entire form
Name: Date of Service:
Preferred / Chosen name (If different from above): Preferred Pronouns:
Date of Birth:
Reason for Visit:
Pharmacy: Pharmacy Phone #:
Address: (Street, City, Zip)
MEDICATIONS
Please list any medications you are currently taking including birth control, creams, aspirin, vitamins, and hormones:
Name of Medication Strength How often you take it
MEDICATION ALLERGIES
Please list any medications you are allergic to:
Medication Your Reaction
Are you allergic to Latex?
She/Her He/Him They/Them
Yes No
108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
MEDICAL CONDITIONS
Do you have or have you had any of the following conditions?
Anemia
□ Yes □ No
Asthma
□ Yes □ No
Diabetes
□ Yes □ No
High Blood Pressure
□ Yes □ No
Stomach Ulcers
□ Yes □ No
Migraines
□ Yes □ No
Seizures
□ Yes □ No
Cancer
□ Yes □ No
Anxiety / Depression
□ Yes □ No
Thyroid Disease
□ Yes □ No
Heart Disease
□ Yes □ No
HIV
□ Yes □ No
Lung Disease
□ Yes □ No
Liver Disease
□ Yes □ No
Hepatitis B or C
□ Yes □ No
Kidney Disease
□ Yes □ No
Intestinal Disease
□ Yes □ No
Bleeding Disorders
□ Yes □ No
Clotting Disorders
□ Yes □ No
Osteoarthritis
□ Yes □ No
Endometriosis
□ Yes □ No
Polycystic Ovarian
□ Yes □ No
If yes, please specify:
Please list any personal history of sexually transmitted illnesses - such as Chlamydia, Gonorrhea, Trichomonas, Syphilis, Herpes, HPV, etc:
DIAGNOSTIC / HEALTH MAINTENANCE
Date of your last Pap smear: Location where you had your last Pap smear: Were the results normal?
Date of your last Mammogram: Location where you had your last Mammogram: Were the results normal?
Have you ever had a colonoscopy? If yes, what year? Location where you had the colonoscopy done:
MENSTRUAL HISTORY
Do you still have a menstrual cycle? When was the rst day of your last menstrual cycle?
What age did you begin your menstrual cycle? # of days between periods: How many days of ow?
Cramping:
Flow:
Are you sexually active?
If yes, what type of birth control do you use?
Yes
Yes
None
None
Yes
No
No Never
Mild
Mild
Moderate
Moderate
Severe
Heavy
No
108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
OBSTETRICAL HISTORY
No. of Pregnancies No. of living children No. of vaginal deliveries
No. of full term births No. of miscarriages No. of Cesarean sections
No. of premature births No. of abortions No. of Ectopic Pregnancies
FAMILY HISTORY (Please mark one)
Mother: Father:
Brother: Sister:
Brother: Sister:
Consider the following relatives when answering these questions: Mother, Father, siblings, children, aunts/uncles, grandparents
Have any family members listed above been diagnosed with the following:
Relative Maternal / Paternal Age of Diagnosis
□ Breast Cancer
□ Uterine Cancer
□ Ovarian Cancer
□ Pancreatic Cancer
□ Colon Cancer
List any medical conditions and cause of death:
Mother:
Father:
Sister(s):
Brother(s):
Living Living
Living Living
Living Living
Deceased Deceased
Deceased Deceased
Deceased Deceased
108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
SOCIAL HISTORY
Do you exercise? What type of exercise? How many times a week?
Occupation / Place of Employment:
Relationship Status: Partner’s Name:
Do you use illicit/street drugs? How often?
Do you drink alcohol? How often?
Do you currently smoke cigarettes? How many per day:
Have you smoked cigarettes in the
past?
If yes, when did you quit?
SEXUAL ORIENTATION / GENDER IDENTITY
We are asking for the following information because we want to understand your individual needs, and improve your care.
We are commited to diversity and inclusion.
What is you current gender identity?
□ Female
□ Male
□ Non-binary/GNC/Genderqueer
□ Transfemale / Male to female
□ Transmale / Female to male
□ Decline to answer
Sexual Orientation:
□ Bisexual
□ Gay
□ Heterosexual
□ Lesbian
□ Don’t know
□ Decline to answer
SURGICAL HISTORY
Please list any surgeries you have had:
Surgery Date
Yes
Yes
Yes
Yes
No
No
No
No
108-16 63
rd
Road, Forest Hills NY 11375 • T: (718) 897-5331 • F: (877) 389-3130 • info@vivaeve.com
FHMS, PC, 1986 Medical, PLLC, 9909 Medical, PLLC
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Patient Name: Date of Birth: Social Security Number:
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form.
In accordance with applicable law, I understand that:
This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line below. In the
event the health information described below includes any of these types of information, and I initial the line on the box below, I specically
authorize release of such information to the person(s) indicated below.
If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited
from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the
right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination be-
cause of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493
or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this
authorization except to the extent that action has already been taken based on this authorization.
I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benets will not
be conditioned upon my authorization of this disclosure.
Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by
federal or state law.
A COPY of this Authorization shall have the same force and effect as original.
Name and address of health provider or entity to release this information:
Viva Eve - 108-16 63rd Road, Forest Hills, NY 11375 Tel: (718) 897-5331 Fax: (877) 389-3138
Name and address of person(s) or category of person to whom this information will be sent:
Specic information to be released:
□ Medical Record from (insert date) to (insert date)
□ Abstract: (all tests, labs, EKGs, echocardiograms, procedure reports, discharge summary etc.)
□ Entire Record
□ Other:
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Reason for release of information:
□ At request of individual
□ Other:
Date or event on which this authorization will expire:
If not the patient, name of person signing form: Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy
of the form.
Signature of patient or representative authorized by law. Date
□ Include: (Indicate by initialing)
*Human Immunodeciency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person's contacts.
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Completed 6 December 2021

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