Christian Family Medicine and Pediatrics

Clinic Location

Patient Information

Legal Name

Birth/Maiden Name

Gender

Social Security #

Marital Status

Date of Birth

Race

Ethnicity

Preferred Language

Preferred Provider

Religion

Dominant Side

Address

Home Phone

Cell Phone

Work Phone

Email Address

Preferred Contact Method

Preferred Reminder Method

Consent: Health Information Exchange

Yes No

Emergency Contact

Emergency Contact #

Emergency Contact Relationship

Pharmacy of Choice

Pharmacy City

Pharmacy Phone

Patient Employer

Status

Full Time Part Time

Employer Phone

Student

Yes No

Status

Full Time Part Time

Insurance Information

Do you have insurance?

Yes No

Insured Relationship to Patient

Insured Name

Date of Birth

Gender

Social Security #

Marital Status

Address

Phone

Primary Insurance

Insurance Co

Effective Date

Copay Amount

Policy #

Group/Plan #

Policy Holder's Name

Policy Holder's Date of Birth

Policy Holder's Social Security #

Address

Phone

Relationship to Patient

Secondary Insurance

Insurance Co

Effective Date

Copay Amount

Policy #

Group/Plan #

Policy Holder's Name

Date of Birth

Social Security #

Address

Phone

Relationship to Patient

Patient Responsibilities Notification

I have read and understand the financial responsibilities outlined here.

I understand that Christian Family Medicine, Inc. is a Patient-Centered Medical Home facility. Read information about PCMH facility.

I understand that I have been made aware of Christian Family Medicine and Pediatrics Notice of Privacy Practices.

Patient Disclosure Authorization

Christian Family Medicine Inc. has provided me notification of their Privacy Practice for protected health information. I authorize Christian Family Medicine, Inc. the release of information including the diagnosis, records; examination rendered to me and claims information.

This Release of Information will remain in effect until terminated by me in writing.

This information may be released to:

Spouse Children Other Information is not to be released to anyone

Spouse Name

Child(ren) Name(s)

Other

For messages, please call my:

If unable to reach me:

Health History

Current Problem

Do you have allergies or intolerance to medications?

Yes No

Please explain...

Do you take any prescription or non-prescription medications. This includes vitamins, supplements, and over the counter pain pills? (Advil, Aleve, Tylenol, etc)

Yes No

Please list ALL of your prescription and non-prescription medicine.

Medication	Dose	How Often?

List any medical suppliers you use (e.g. respiratory supplies, etc)

Please list health care providers and their specialty you see regularly

Preventitive Testing

Colonoscopy

Stress Test

Eye Exam

Dental Cleaning

Wear contacts or glasses Wear hearing aids

Please list immunizations and provide date of immunizationYou can also provide a printed record at the time of your appointment.

Immunization	Date

Do you have any metal in your body?

Yes No

Mammogram

Most recent date

Where?

Abnormal?

Yes No

Pap Smear

Most recent date

Where?

Abnormal?

Yes No

Bone Density Test

Most recent date

Where?

Abnormal?

Yes No

Total # of pregnancies

# of live births

# of miscarriages

# of abortions

Age period started

Age period stopped

Current method of birth control

Hysterectomy

Yes No

Are you currently experience any of the following?

Prostate Issues Erectile Dysfunction Impotence Other

Medical History

Please indicate if you have had the following diseases and let us know if the condition is Current or Not-Current. In the comment box at the bottom, list family members who have had these conditions and whether the condition caused the person's death. When choosing "myself" for having any of the conditions below, choose either "Myself C," meaning you currently have the condition or "Myself P," meaning you had the condition in the past, but no longer have it now.

I do not have any of these conditions

Surgical & Procedure History

Please check if you have had the surgery or procedure listed.

Use this box to explain any abnormal findings or complications with conditions listed above. Also list any surgeries or procedures you have had that are not listed above.

Health Issues

Tobacco Use Check all that apply

Current Smoker

Packs per day: # of years:

Former Smoker

Quit date: Approx packs/day: # years smoked:

Other Information

Social Documentation

Name you prefer we use when contacting you

Country of Birth

Who lives at home with you?

Please list your interests, hobbies, group involvement, volunteer work, and/or travel outside of the country in the past 6 months

Socioeconomic

Occupation (or prior)

Employer

If you are not currently working, you are

Spouse/Partner's Name

# of Children

Ages of Children (if minors)

Medical Forms

Please check any of the following forms you have completed

Advance Directive for Health Care (ADHC) POLST (Physician Orders for Life Sustaining Therapy Durable Power of Attorney (DPA) for healthcare decisions Living Will Know about these or have the forms but have not completed them Don't know what these are

By checking this box on this online form, I certify that the information I’ve filled out above is correct.

Patient Name

Date

Adult New Patient Registration

Primary Insurance

Secondary Insurance

Social Documentation

Socioeconomic

Medical Forms

Forms

Resources