PATIENT RESGESTRATION FORM

THE HOSPITALPATIENT RESGESTRATION FORMTime & Date of Admission: ______________________ ID NO: ______________________________Patient Name: ___________________________ Father Name: ________________________________Age: _____ Sex: ________ Height: _____ cm weight: ______ kg BMI: ________ Occupation: ________________________ Work place: ___________________________________EMPLOYERS NUMBER: (_____) _____ – _______ CIVILIAN □ YES □ NOADDRESS: ____________________________________________________________________________PERSONAL CONTACT INFORMATIONEMAIL ADDRESS:Home Phone: (____) _____ – _______ Cell Phone: (____) _____ – _______ Alt Phone: (____) _____-___Marital Status: □ Single □ Married □ Divorced □ Widowed Spouse’s Name: __________________ Spouse’s Phone: (____) ____-______ Race: □ Asian □ White □ American Indian/Alaska Native □ Hispanic □ African American □ Other: ____Language: □ English □ Spanish □ Other: ________________ EMERGENCY CONTACT INFORMATIONName: _______________________________________Relationship: ____________________________ Home #: (_____) _____ – _______ Cell #: (_____) _____ – _______ Alternate #: (_____) _____ – _______INSURANCE INFORMATIONPolicy Holder: ______________________________ SSN # _____-_____-______ D.O.B ____/____/_____ Primary Insurance Company: ____________________ Policy #________________ Group # _________Secondary Insurance Company: ____________________ Policy # ________________ Group #___________REASON FOR VISIT: MEDICAL EMERGENCY □ TRAUMA □ INJURY □ ILLNESS □ FOLLOW UP □Date of inciting injury or accident _____________ REFFERED BY: Doctor □ phone# __________________ Hospital: _______________________________Insurance Company □ Friend/Family □ Internet □ VA □ Other_____________ PAST MEDICAL HISTORY (check all that apply)HTN □ hyper/hypo lipedema □ Diabetes □ Renal Failure □ Anemia □ bleeding disorder □ Migraine□ Seizures □ Stroke □ Heart Attack □ Heart Failure □ Osteoporosis □ arthritis □ Chronic Pain □ hepatitis□ Lung Disease □ TB □ Liver Disease □ Cancer □ _____________________ Mental illness □ Congenital disorder □ __________________ any other comorbidity _________________ Allergies: Food □ Latex □ drug □ pollen □ other _____________ SOCIOECNOMIC HISTROYAddiction Yes □ No □ _________________________________smoking Yes □ No □ ____packs/day alcohol □ Yes □ No □ chew tobacco □ Yes □ No □sleep normal yes □ no□ appetite □ depression Yes □ No diet normal? Yes □ No bowel & bladder normal? yes □ no□with home do you live? ____________________ Family members: ____________ no.Socioeconomic status: lower class □ middle class □ upper class □Medicines: YES □ NO □ (if yes then mention drug name and doses)_____________________ ____________________ ___________________ __________________________ ____________________ ____________________ ____________________ __________________________ ____________________ ____________________ _____________________ ________________________________________________ ____________________ _______________________ _________________________ PAST SURGICAL HISTORYType of Surgery Year Type of Surgery Year _________________________ ___________ ____________________________ ___________ _________________________ ___________ ____________________________ ___________ _________________________ ___________ ____________________________ ___________ _________________________ ___________ ____________________________ ___________ FAMILY HISTORY (check all that apply, Mother M/Father F)Stroke M/F □ Diabetes M/F □ Seizures M/F □Heart Disease M/F □ High Blood Pressure M/F □ Mental Illness M/F □ Arthritis M/F □ Gout M/F □ Cancer M/F ________ □ Bleeding Disorders M/F □PRESENTING COMPLAIN: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Chief Complaint: ____________________________________________________________________________ ___________________________________________________________________________________________Onset of symptoms _______________________Do you have pain? Yes □ No □ Duration of pain: constant □ intermittent □ only when ___________________ Nature of pain: □ Sharp □ Dull □ Achy □Burning □ Spasms □ Other __________________Do you feel trouble in doing activities of daily living? □ Yes □ No Aggravating factors: □ Sitting □ Standing □ Walking □ Lying Down □Bending/twisting □ Other____Relieving factors: Sitting □ Standing □ Walking □ Lying Down □ Bending□ icing □ Other_______Currently receiving any treatment? Yes □ No □ Pain killers, Narcotic/Opioid pain medication □ Anti-inflammatory medication □ Physical Therapy □ Acupuncture □ Oral steroids □ Bracing □ Muscle relaxants □ Acupuncture □ Chiropractic Manipulation □ massage □FUNCTIONAL STATUS: Dependent □ independent □ partially dependent □Labs: ___________________________________________________________________________Radiographic Reports: CT □ MRI □ X-RAY □ DEXA □ other_________________________________Findings: ________________________________________________________________________Female Patients Only Pregnant: Yes □ No □ gestational age ______ Name of OB/Gyn _______________________Systemic review:GENERAL: Fever □ Chills □ Weight loss □ Fatigue □ Other______EYES Blurred vision□ photophobia□ Eye pain□ Double vision□ Other______CVS Chest pain□ palpitations□ Peripheral edema□ Other______RESPO Shortness of breath□ cough□ Recent infections□ Other______GI constipation□ Abdominal pain□ Bowel incontinence□ nausea□ Vomiting□ Other______GENITOURINARY dysuria□ Bladder incontinence□ Other______MSK Joint pain□ swelling□ warmth□ spasm□ Cramps□ Other______INTEG lesion□ rash□ Pressure ulcer□ Other______HEME/LYMPH bleeding□ Bruising□ Anemia □ Other______CNS weakness□ numbness□ Loss of balance□syncope□ headache□ tingling□ Other____PSYCHIATRIC: depression□ anxiety□ hallucinations□ Other___________ENT Decreased hearing□ tinnitus□ dysphagia□ Other___________IMMUNOLOGIC AIDS□ Persistent infection□ Hay fever□ hives□ Other___________FINANCIAL AGREEMENTI, ______________________________ acknowledge the services and care provide by The Hospital and. I understand the services which includes medical agents’ necessities that I received or requested for and therefore I’m responsible for all of my bill payments which are not covered by my insurance company.SIGNATURE: ____________________________ DATE: __________________________ CONSENT FOR TREATMENTI have been informed by the DR ___________________________________ about my disease/ condition, to provide me a quality of care and for the betterment of health I give consent to the Dr.___________________________ for my treatment and allow him to provide me intervention which is beneficial for my health. I have a believe in medicine and I know that there is no magic done by the medicines it’s only work on body conditions to treat the ailments, therefore no guarantee can be made for the results of treatment and anything could happen to me for which hospital and doctors are not responsible. I am giving this consent without any confusion, stress or pressurization of my colleagues, family, physician or hospital. NAME: ___________________________________________________ SIGNATURE: __________________________ TIME: ____ DATE: ________________________CONSENT FOR DISCLOUSER OF MEDICAL INFORMATIONI have given the consent to hospital to disclose my health condition and share the copy of my file with my family members or with _______________________________ (specify the person). And permitted them that can □ or can’t □ use my data for any kind of research purposes. NAME: __________________________________________________SIGNATURE: _________________________ TIME: _____ DATE: ________________________CONSENT FOR ADVANCED PRACTIONER TREATMENTI grant the consent to medical officer and a staff nurse to provide me care under the supervision of physician and only provide me treatment according to doctor’s orders. And in case of any medical emergency I can call my physician and he’ll be available. NAME: __________________________________________________SIGNATURE: _________________________ TIME: _____ DATE: ________________________ PERMISION TO LEAVE A MESSAGEI acknowledge the hospital that they may contact with me via email or contact numbers that I’ve provided.NAME: __________________________________________________SIGNATURE: _________________________ TIME: _____ DATE: ________________________

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