pinnacle medical group patient registration form · pinnacle medical primary care patient name:...
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Pinnacle Medical Group Patient Registration Form PATIENT INFORMATION (Please Print)
Dr. Miss Mr. Mrs. Ms. SirPatient’s Name (Last)_________________________________ (First)____________________________ (MI) ______________ Previous Name (Last) ______________________________________ (First) _________________________________________Address___________________________________________City_______________________ State_____ Zip ______________Home Phone_______________________ Cell_______________________ Work________________________ Ext. ________Primary Care Provider (PCP)____________________________ Referring Provider ____________________________________Email Address ___________________________________________________________________________________________Date of Birth _______/_______/_________ Female Male Transgender Race American Indian or Alaska Native Asian Native Hawaiian or other Pacific Island Black or African American White Decline
Ethnicity Hispanic or Latino Not Hispanic or Latino DeclinedLanguage English Spanish Japanese Chinese French German Russian Other __________Marital Status Married Single Divorced Widowed Legally Separated PartnerSocial Security No. ________-_______-__________ Employer Name _____________________________________________Employment Status 1 - Full Time 2 - Part Time 3 - Not Employed 4 - Self-Employed 5 - Retired 6 - Active Military
Student Status F - Full Time Student P - Part Time Student N - Not a Student Do you have a living will? Yes No
Emergency Contact Name________________________________________ Phone Number _____________________________Emergency Contact Relationship to Patient __________________________________________________________ GuardianHome Phone_______________________ Cell_______________________ Work________________________ Ext. ________
RESPONSIBLE PARTY INFORMATION (Information used for patient balance statements)
Responsible Party Guarantor SelfResponsible Party Name (Last)______________________________ (First)____________________________ (MI) _________ Also Known As Name (Last) ______________________________________ (First) ____________________________________Date of Birth _____/_____/________ Female Male Social Security No. _______-______-_______Home Phone_______________________ Cell_______________________ Work________________________ Ext. ________Address___________________________________________City_______________________ State_____ Zip ______________Employer________________________________________________ Employer Phone _________________________________
PRIMARY INSURANCE INFORMATION (Provide your insurance card to the front desk at check-in)
Insurance Company _____________________________________ Insurance Company Phone __________________________Name of Insured________________________________________ Patient Relationship to Insured ________________________Subscriber ID (Policy Number)__________________________ Group ID____________________ Copay Amount____________Effective Date_____/_____/________ Termination Date_____/_____/________ Date of Birth _____/_____/________
SECONDARY INSURANCE INFORMATION (Provide your insurance card to the front desk at check-in)
Insurance Company _____________________________________ Insurance Company Phone __________________________Name of Insured________________________________________ Patient Relationship to Insured ________________________Subscriber ID (Policy Number)__________________________ Group ID____________________ Copay Amount____________Effective Date_____/_____/________ Termination Date_____/_____/________ Date of Birth _____/_____/________
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient (or Responsible Party) Signature_____________________________________________ Date_____/_____/________
PinnacleMedical Group 8/13
Pinnacle Medical Primary Care
MEDICAL HISTORY FORM
Date: _________________________ Date of Last Physical Exam: _____________________
Patient Name: _____________________________________________________ Date of Birth: ___________________
Patient Current Concerns: __________________________________________________________________________
Preferred Pharmacy: ______________________________________ Phone: _____________________________
MEDICATIONS ALLERGIESLIST ALL MEDICATIONS YOU ARE CURRENTYLY TAKING ___________________________________________INCLUDE VITAMINS, HERBS, SUPPLEMENTS, ETC. ___________________________________________
SOCIAL HISTORYDo you smoke? YES NO How much per day? ____
If you quit smoking, when? ______Do you use a vape? YES NOIf yes, how often do you vape? _______How many years have you smoked? ______
PLEASE LIST ANY OF THE FOLLOWING THAT APPLY TO YOUR HEALTH (w/ dates if applicable):CHRONIC CONDTIONS ACCIDENTS/INJURIES HOSPITALIZATIONS_________________________ ____ ____________________________ ____________________________________________________________ ____________________________ ______________________________SURGERIES DIAGNOSTIC TESTS RECENT LABS
______________________________ ______________________________ ______________________________
______________________________ ______________________________ ______________________________
LAST COLONOSCOPY FLU VACCINE PNEUMONIA VACCINE
______________________________ _____________________________ ______________________________
(Female patients)
LAST MAMMOGRAM LAST PAP SMEAR DO YOU TAKE ORAL CONTRACEPTIVES? YES NO
______________________________ ________________________
DIABETIC PATIENTS When was your last eye exam? _________________ Where? _____________________________How often do you check your blood sugar? ___________________ What was your last A1C result? ________________
65 AND OVER Have you fallen in the past year? YES NO If yes, do you know what caused the fall? _______________
CERTIFICATIONTo the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
_______________________________________________________________ _______________Signature of Patient, Parent, Guardian or Personal Representative Date
_______________________________________________________________ ________________Please print name of Patient, Parent, Guardian or Personal Representative Date
Pinnacle Medical Primary Care
Patient Name: _____________________________________________________ Date of Birth:_______________________________
PATIENT HEALTH QUESTIONNAIRE
We are asking questions pertaining to your current mood to assess your physical as well as psychological well-being. We understand the sensitivity of these questions and assure you that your answers will remain private.
Over the past two weeks, how often have you been bothered by any of these problems?
LITTLE INTEREST OR PLEASURE IN DOING THINGS? YES NO FEELING DOWN, DEPRESSED, OR HOPELESS? YES NO
If you answered YES to either of the above questions above please proceed with answering the following:
Over the last 2 weeks, how often have you been botheredby any of the following problems?(Use “✔” to indicate your answer)
Nearlyeveryday
Morethan halfthe days
SeveraldaysNot at all
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3
7. Trouble concentrating ont things, such as reading the newspaper or watching television 0 1 2 3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless 0 1 2 3 that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3