New Patient Form

Personal Information - Step 1 of 8

Social Security #

Date of Birth

Age

Sex

Male
Female

Marital Status

Patient's Name:

First

Middle

Last

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Telephone:

Work Telephone:

Ext

Cell:

Employer:

Occupation

Employment Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Tel :

Relationship

Patients under the Age of 18

Parent or Guardian Name:

First

Middle

Last

Home Telephone:

Work Telephone:

Ext

Cell:

Primary Insurance

Plan Name:

Effective Date:

Insurance

Primary
Secondary

ID #

Group #

Plan Telephone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Policy Holder's Name

D.O.B

SS#:

Policy Holder's Employer

Relationship to Patient

Secondary Insurance

Plan Name:

Effective Date:

Insurance

Primary
Secondary

ID #

Group #

Plan Telephone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Policy Holder's Name

D.O.B

SS#:

Policy Holder's Employer

Relationship to Patient

Referred By

Physician
Insurance Company
Family/Friend
Phone Book
Internet
Other

Whom Can We Thank For the Referral (Name)

Do you have an Advance Medical Directive?

If yes, please provide a copy for your record; If No, please ask for information.

May we contact you to confirm your appointment?

If yes, please indicate preferred Means of Contact and mention 1‐2‐3 in order of priority

Telephone #

Text

Is it okay to leave a Message on your voice mail reminding you of your appointment?

Assignment of Benefits and Authorization to Release Medical Information

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plan to: Beauregard Medical Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment isto be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance within 45 days. Should it become necessary to turn my account over to an outside collection agency I will be responsible for collection cost, attorney fees, litigation fees and court costs. I hereby authorize Beauregard Medical Center and its employees and agents, to release all information, reports and records if necessary to secure the payment of my account, including a discussion of my medical condition, to the insurance provider, rehabilitation provider, employer, hospitals, and doctors.

Patient/ Policy Holder

Date

Responsible Person if Patient is a Minor:

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Name

First

Middle

Last

DOB:

MM/DD/YYYY

Marital status:

Single
Partnered
Married
Separated
Divorced
Widowed

Previous or referring doctor: Date of last physical exam:

Date of last physical exam:

Race:

Ethnicity:

PERSONAL HEALTH HISTORY

Multiple Choice

Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio

Others:

Immunizations and dates:

Tetanus

Pneumonia

Hepatitis

Chickenpox

Influenza

MMR Measles, Mumps, Rubella

List any medical problems that other doctors have diagnosed, when and if Resolved

Surgeries

Year

Reason

Hospital

Year 2

Reason 2

Hospital 2

Year 3

Reason 3

Hospital 3

Year 4

Reason 4

Hospital 4

Year 5

Reason 5

Hospital 5

Other hospitalizations

Year

Reason

Hospital

Year (copy)

Reason (copy)

Hospital (copy)

Year (copy) (copy)

Reason (copy) (copy)

Hospital (copy) (copy)

Year (copy) (copy) (copy)

Reason (copy) (copy) (copy)

Hospital (copy) (copy) (copy)

Year (copy) (copy) (copy) (copy)

Reason (copy) (copy) (copy) (copy)

Hospital (copy) (copy) (copy) (copy)

Have you ever had a blood transfusion?

List your prescribed drugs and over‐the‐counter drugs, such as vitamins and inhalers

Name the Drug

Strength

Frequency Taken

Name the Drug (copy)

Strength (copy)

Frequency Taken (copy)

Name the Drug (copy) (copy)

Strength (copy) (copy)

Frequency Taken (copy) (copy)

Name the Drug (copy) (copy) (copy)

Strength (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Name the Drug (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Strength (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Frequency Taken (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Allergies to medications

Name the Drug

Mild/Moderate/Severe

Type of Reaction

Name the Drug (copy)

Mild/Moderate/Severe (copy)

Type of Reaction (copy)

Name the Drug (copy) (copy)

Mild/Moderate/Severe (copy) (copy)

Type of Reaction (copy) (copy)

Name the Drug (copy) (copy) (copy)

Mild/Moderate/Severe (copy) (copy) (copy)

Type of Reaction (copy) (copy) (copy)

Non‐Drug Allergies

Name the Drug

Mild/Moderate/Severe

Type of Reaction

Name the Drug (copy)

Mild/Moderate/Severe (copy)

Type of Reaction (copy)

Name the Drug (copy) (copy)

Mild/Moderate/Severe (copy) (copy)

Type of Reaction (copy) (copy)

Name the Drug (copy) (copy) (copy)

Mild/Moderate/Severe (copy) (copy) (copy)

Type of Reaction (copy) (copy) (copy)

MENTAL HEALTH

Is stress a major problem for you?

Do you feel depressed?

Do you panic when stressed?

Do you have problems with eating or your appetite?

Do you cry frequently?

Have you ever attempted suicide?

Have you ever seriously thought about hurting yourself?

Do you have trouble sleeping?

Have you ever been to a counselor?

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise

Sedentary (No exercise)

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)

Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)

Diet

Are you dieting?

If yes, are you on a physician prescribed medical diet?

# of meals you eat in an average day?

Rank salt intake

Rank fat intake

Caffeine

None
Coffee
Tea
Cola

Alcohol

Do you drink alcohol?

If yes, what kind?

How many drinks per week?

Are you concerned about the amount you drink?

Have you considered stopping?

Have you ever experienced blackouts?

Are you prone to “binge” drinking?

Do you drive after drinking?

Drugs

Do you currently use recreational or street drugs?

Have you ever given yourself street drugs with a needle?

Do You Take Birth Control Pills ?

Do You Take Tranquilizers?

Others

Do You Take Stimulants/Pep Pills?

Do You Take Vitamins?

Do You Take Laxatives?

Do You Take Sedatives/Sleeping Pills?

Smoking

Smoking Status

Current Smoker
Former Smoker
Never smoked

If Current or Former Smoker, Please answer the following Questions:

Cigarettes – pks./day

Chew ‐ #/day

Pipe ‐ #/day

Cigars ‐ #/day

# of years

Or year quit

WOMEN ONLY

Age at onset of menstruation:

Date of last menstruation:

Period every

Days

Heavy periods, irregularity, spotting, pain, or discharge?

Number of pregnancies

Number of pregnancies (copy)

Are you pregnant or breastfeeding?

Have you had a D&C, hysterectomy, or Cesarean?

Any urinary tract, bladder, or kidney infections within the last year?

Any blood in your urine?

Any problems with control of urination?

Any hot flashes or sweating at night?

Any hot flashes or sweating at night? (copy)

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Experienced any recent breast tenderness, lumps, or nipple discharge?

Date of last pap and rectal exam?

MEN ONLY

Do you usually get up to urinate during the night?

If yes, # of times

Do you feel pain or burning with urination?

Any blood in your urine?

Do you feel burning discharge from penis?

Has the force of your urination decreased?

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Do you have any problems emptying your bladder completely?

Any difficulty with erection or ejaculation?

Any testicle pain or swelling?

Date of last prostate and rectal exam

Personal Information

Social Security #:

Date of Birth:

Age

Sex

Male
Female

Patient's Name:

First

Middle

Last

Patient's Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Telephone:

Work Telephone:

Ext

Cell:

(Please check the information you are requesting)

Office Visit Notes
Laboratory Reports
EKG/Stress/Echo/Holder
X-Rays Reports
Allergy Records
Immunizations
All Records
Outside Reports

, do hereby authorize Beauregard Medical Center to release or get

Please Select on Opinion:

Release
Get

Records From

Name of Company/Agency/Facility/Person

Address Line 1

Address Line 2

City

State

Zip Code

Purpose of Disclosure:

I do

NOT authorize release of information related to AIDS or HIV, psychiatric care and/or psychological assessments and treatment for alcohol and / or drug abuse

I hereby authorize disclosure of the health information above. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information release prior to notification of cancellation, I understand that the information used or disclosed may be subject to re-disclosure by the person or class of person or facility receiving it, and would then no longer be protected by federal regulations.

Patient/Guardian/Legal Representative

Date

****** Note: There will be a charge for personal copy and permanent transfer of your records *****