Fillable PATIENT REGISTRATION INFORMATION Please email your completed paper

Fill Online, Printable, Fillable, Blank PATIENT REGISTRATION INFORMATION Please email your completed paper Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PATIENT REGISTRATION INFORMATION Please email your completed paper

On average this form takes 109 minutes to complete

The PATIENT REGISTRATION INFORMATION Please email your completed paper form is 16 pages long and contains:

  • 0 signatures
  • 334 check-boxes
  • 282 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Name:
_______________________
DOB: ________________________
PATIENT REGISTRATION INFORMATION
Patient Name (Last, First, Middle):
Social Security #:
-
- Age: Date of Birth:
/ /
Sex:
q
Male
q
Female
Language:
Marital Status:
Race:
Ethnicity: qHispanic or Latino qNot Hispanic or Latino
Address:
City:
State: Zip Code:
Telephone #:
Cell Phone #:
Email Address:
Employer:
Occupation:
Employer Address:
City:
State: Zip Code:
Employer Telephone #:
Extension:
Primary Care Physician:
Telephone #:
Referring Physician:
Telephone #:
EMERGENCY CONTACT
Name:
Relationship to Patient:
Telephone #:
Employer Telephone #:
Please email your completed paper work to russell.vieaux@baileymedicalcenter.com or fax it to 918.550.6632.
1
Name: _______________________
DOB: ________________________
GUARANTOR INFORMATION
Name:
Relationship to Patient:
Social Security #:
-
-
Age:
Date of Birth:
/
/
Sex:
q
Male
q
Female
Address:
City:
State:
Zip Code:
Telephone #:
Cell Phone #:
Employer:
Employer Telephone #:
PRIMARY INSURANCE
Insurance Name:
Insurance Telephone #:
ID #:
Group #:
Claims Mailing Address:
City:
State:
Zip Code:
Subscriber’s Name:
Relationship to Patient: qSelf
qSpouse
qChild
Subscriber’s Employer:
Subscriber’s Address:
City:
State:
Zip Code:
Subscriber’s Social Security #:
-
-
Subscriber’s Date of Birth:
/
/
SECONDARY INSURANCE
Insurance Name:
Insurance Telephone #:
ID #:
Group #:
Claims Mailing Address:
City:
State:
Zip Code:
Subscriber’s Name:
Relationship to Patient: qSelf
qSpouse
qChild
Subscriber’s Employer:
Subscriber’s Address:
City:
State:
Zip Code:
Subscriber’s Social Security #:
-
-
Subscriber’s Date of Birth:
/
/
2
Name: _________
______________
DOB: ________________________
MEDICAL HISTORY
If Over the Age of 50, Have You Had a Colonoscopy?
q
No
q
Yes
If Yes, When?
FOR MALES ONLY:
Have You Had a Prostate Exam?
q
No
q
Yes
If Yes, When?
FOR FEMALES ONLY:
Have You Had a Mammogram?
q
No
q
Yes
If Yes, When?
Have You Had a Pap/Pelvic Exam?
q
No
q
Yes
If Yes, When?
Is It Possible You are Currently Pregnant?
q
No
q
Yes
Last Menstrual Period:
/
/
Current Contraceptive Method:
# of Pregnancies:
# of Live Births:
1
st
Pregnancy … Age:
Weight Gain:
3
rd
Pregnancy … Age:
Weight Gain:
2
nd
Pregnancy … Age:
Weight Gain:
4
th
Pregnancy … Age:
Weight Gain:
3
Name: __________________
_____
DOB: ________________________
MEDICAL HISTORY CONTINUED
Illness/Diagnosis (please
check all that apply):
q Diabetes – requires insulin
q Diabetes – requires no insulin
q HIV Exposure/AIDS
q Thyroid Disease
q Insulin Resistance
q Irregular Menstrual Periods
q Morbid Obesity – 5+ Years
q Polycystic Ovarian
Syndrome
q Weight Gain
q Asthma
q Blood Clots-DVT
q Blood Clots to Lungs-PE
q Emphysema (COPD)
q Lung Disease/COPD
q Pneumonia
q Shortness of Breath w/
Activity
q Shortness of Breath at Rest
q Sleep Apnea
q Sleep Apnea – CPAP
Machine
q Sleeping Problems
q Snoring
q Tuberculosis
q Chest Pain w/ Activity
(Angina)
q Chest Pain at Rest (Angina)
q Chronic Leg Sores
q Congestive Heart Failure
q Heart Attack
q Heart Disease
q Heart Palpitations
q High Blood Pressure
q High Cholesterol
q Irregular Heart Rate or
Rhythm
q Leg Discoloration
q Leg Swelling/Edema
q Swelling of Ankles/Feet
q Aspiration/Choking
q Chronic Abdominal Pain
q Heartburn or Reflux
q Hiatal Hernia
q Nausea
q Nausea-Vomiting
q Stomach Ulcers
q Trouble Swallowing
q Ulcers/Gastritis
q Arthritis
q Chronic Back Pain
q Chronic Fatigue
q Chronic Joint Pain
q Chronic Headache
q Seizure Disorder
q Stroke
q Anxiety
q Bipolar Disorder
q Depression
q Low Self-Esteem
q Panic Attacks
q Drowsy Days
q Exercise Limitations-mild
q Exercise Limitations-
moderate
q Exercise Limitations-severe
q Fevers/Chills/Sweats
q Frequent Colds
q Gallbladder Attacks
q Gallbladder Disease
q Iron Deficient Anemia
q Skin Rash
q Urinary Incontinence
q Vitamin D Deficiency
q Cancer
Please list any other illness/diagnosis:
4
Name: _______________________
DOB: ________________________
MEDICAL HISTORY CONTINUED
Physical Limitations/Disabilities (please check all that apply):
q Airline Travel
q Lifting Objects from Floor
q Unusual Fatigue
q Caring for Personal Needs
q Playing with Children
q Use of Public Seating
q Climbing Stairs
q Tying Shoes
When Exposed to the Following, Do You Have Symptoms Like Red Itchy Eyes, General Itching, Shortness of Breath,
Wheezing, Fast Heartbeat, Feeling Faint, Nausea or Vomiting…
Aspirin?
q Yes q No Iodine? q Yes q No
Latex?
q Yes q No Rubber (Balloons, Band-Aids, Spandex, Tape)? q Yes q No
Please List Any Previous Cardiac Procedures or Testing and Cardiologist Name:
FAMILY MEDICAL HISTORY
Illness/Diagnosis (please check all that apply):
q
No information q Kidney Disease
qMother qFather qOther____________
q Diabetes q Liver Disease
qMother qFather qOther____________ qMother qFather qOther____________
q Morbid Obesity q Bleeding Disorder
qMother qFather qOther____________ qMother qFather qOther____________
q Heart Disease q Cancer
qMother qFather qOther____________ qMother qFather qOther____________
q High Blood Pressure q Clotting Disorder
qMother qFather qOther____________ qMother qFather qOther____________
q Heart Attack q Breast Disease
qMother qFather qOther____________ qMother qFather qOther____________
q Asthma q Stroke
qMother qFather qOther____________ qMother qFather qOther____________
q Emphysema/COPD q Arthritis
qMother qFather qOther____________ qMother qFather qOther____________
q Bowel/Colon Disease qDepression/Anxiety
qMother qFather qOther____________ qMother qFather qOther____________
q Hepatitis
qMother qFather qOther____________
q Other: _________________________________ q Other: _________________________________
q Other: _________________________________ q Other: _________________________________
q Other: _________________________________ q Other: _________________________________
5
Name: _________
______________
DOB: ________________________
SURGICAL HISTORY
Surgical Procedures (please check all that apply):
q Back/Neck Surgery
q Roux-N-Y Gastric Bypass
q Surgery to the Small Bowel
q Caesarean Section
q Sleeve Gastrectomy
q Surgery to the Stomach
q Dilation & Curettage (D&C)
q Surgery to the Chest or Lung
q Tonsillectomy
q Gallbladder
q Surgery to the Esophagus
q Other:
q Gastric Banding
q Surgery to the Heart
q Other:
q Hysterectomy
q Surgery to the Large Bowel
q Other:
Surgical Compli
cations (please check all that apply):
q Anesthesia Problems
q Blood Transfusion
q Other:
q Bleeding
q Infections
q Other:
Please List Oth
er Significant Conditions or Hospitalizations:
NUTRITIONAL HISTORY
# of Meals Per Day:
Do You Eat Between Meals? q Yes qNo # of Glasses of Water Per Day:
Food Preferences (please check all that apply):
q Cakes/Pies
q Cookies
q Pizza
q Candy
q Dairy Products
q Seafood
q Chips/Snacks
q Fast Food
q Steak/Red Meat
q Chocolate
q Fried Food
q Vegetables
Do You Use Tobacco? qNo qYes
SOCIAL HISTORY
If Yes, What Type? qChew qCigarettes qCigar
qPipes
# Per Day: ____________ # of Years ___________ If you Quit, When? _____________________________________________
Do You Drink Sodas?
qNo qYes If Yes, What Type? qDiet qRegular # Per Day _________________________________
Do You Drink Alcoholic Beverages?
qNo qYes If Yes, How Many Times Per Week? ________________________________
Do You Drink Coffee/Caffeine?
qNo qYes If Yes, How Many Cups Per Day? ___________________________________
Have you Ever Used Marijuana or Other Illicit Drugs?
qNo qYes
Do You Tolerate Physical Exercise?
qNo qYes
Do You Have Trouble Sleeping?
qNo qYes
6
Name: _______________________
DOB: ________________________
MEDICATIONS
Please list any medication allergies:
Preferred Pharmacy: _________________________________________________________
Location/Address: ___________________________________________________________
CURRENT MEDICATIONS
Medication Name
Strength
Frequency
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
____________________________
_____________
_____________
q Prescription
q Over-the-Counter
7
Name: _______________________
DOB: ________________________
WEIGHT LOSS HISTORY
Diet Year(s) Weight Lost # of Months on Program
Acupuncture Behavior
Modification Exercise
Fen-Phen
Hypnosis
Injections
Jenny Craig
Meridia
Nutritionist/Dietitian
Psychiatrist/Therapy
Opti-Fast
Overeaters Anonymous
Redux
Richard Simmons
Weight Watchers
Xenical
Physician-Directed Plan(s)
List:
List:
Self-Monitored Diet(s)
List:
List:
8
Patient Name: ______________________________ DOB:______________________
If yes, when and where:
________________________________________________
Current use of CPAP?
If you have been previously diagnosed with Obstructive Sleep
Apnea and instructed to use a CPAP do you use it daily as
prescribed?
Do you have a personal history of any of the following?
1. Abnormal movement, behavior, emotions, or dreams while sleeping
2.
Previous home sleep study which did not diagnose OSA
3.
4.
Excessive Daytime Sleepiness
5.
Insomnia? (Inability to sleep)
6. Has anyone ever told you that you stopped breathing during sleep?
7. Have you experienced gasping or choking while sleeping?
8.
Do you frequently arouse during sleep?
If you answered yes to any of the above symptoms, how long have you been experiencing them?
_____________________________________________________________________________________
9
Do you have a personal medical history for any of the following?
9. High Blood Pressure
10. Use of three or more medications to treat High Blood Pressure
11. Any head or facial or upper airway soft tissue abnormality
12. euromuscular disease
13. Stroke in the past 30 days?
14. “Mini strokes” (Transient ischemic attacks (TIA))
15. Coronary artery disease (CAD)
16. Heart Disease
17. No Fast heart rate (tachycardia)
18. Slow heart rate (bradycardia)
19. COPD/Emphysema/Lung Disease/Asthma
20. Congestive Heart Failure (CHF)
21.
22. Narcolepsy
23. Nocturnal Seizures
24. Use of home oxygen
25. Use of prescription narcotic pain medication
*** To be filled out by clinic staff only***
BMI ________
Neck circumference ________ inches
Pleas
e
email your completed paper work to russell.vieaux@baileymedicalcenter.com or fax it to 918.550.6632.
10
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PATIENT REGISTRATION INFORMATION Please email your completed paper

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document