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QUALITY HEALTH FAMILY MEDICAL CARE REGISTRATION FORM

Patient Infromation
Salutation	Last Name	First Name	Middle Name	Marital Status
Mr Mrs Ms Miss				Select Single Married Divorced Widowed Separated
Sex	Date of Birth	Age	Home Phone	Cell Phone
Male Female Female at Birth Identifies as Male Identifies as Female Female-to-Male/Transgender Male Male-to-Female/Transgender Female Neither exclusively male nor female
Zip Code	City	State	Street Address
		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington DC Washington West Virginia Wisconsin Wyoming
Occupation:	Employer:	Your Email:	Referred to clinic by
			Select Physican Family member A Friend Insurance Plan Web search
Emergency Contact
Name:	Relationship to patient:	Contact Email:	Cell Phone	Additional Phone
	Select Spouse Mother Father Other Relationship
Insurance information
Select this checkbox if self pay
Primary Insurance Name	Insurance ID:	Copay	Deductible	Co-insurance
Subscriber’s name:	Subscriber’s DOB::	Subscriber’s SS:	Subscriber’s relationship to the patient:	Subscriber’s Phone
			Select Self Spouse Mother Father Other Relationship
Secondary Insurance Name	Insurance ID:	Copay	Deductible	Coinsurance
Subscriber’s name:	Subscriber’s DOB::	Subscriber’s SS:	Subscriber’s relationship to the patient:	Subscriber’s Phone
			Select Self Spouse Mother Father Other Relationship

HEALTH HISTORY

Past Medical History

Have you ever had any of the following? Please check all pertinent boxes:

Anemia Chickenpox High Blood Pressure Scarlet Fever Aids or HIV+ Diabetes Infectious Mono Shingles Arthritis Diphtheria Kidney Disease Sleep Apnea Asthma Epilepsy /Seizures Measles Stroke Back Trouble German Measles Migraine Headaches Thyroid Disease Bladder Infections Glaucoma Mitral Valve Prolapse Tuberculosis(or Positive PPD test) Bleeding Tendency Heart Attack Mumps Ulcer Blood Transfusions Heart Disease Pneumonia or pleurisy Varicose Veins Bronchitis Hemorrhoids Polio Venereal Disease(STD) Cancer Hepatitis Rheumatic Fever Whooping Cough

Other Medical Conditions:

Past Surgical History

Have you ever had any of the following? Please check all pertinent boxes:

Abdominal Aneurysm Repair Heart Valve Repair Pacemaker Placement Cesarean section Aortic Valve Replacements(TAVR) Hemorrhoidectomy Weight Loss Surgery Heart Bypass Surgery Appendectomy Hip Replacement Surgery Ablation Hernia Surgery Cardio Angioplasty & Stent Placement Hysterectomy Appendectomy Partial Colectomy Carotid Surgery Low Back Surgery Breast biopsy Prostatectomy Coronary Artery Bypass Surgery Mastectomy Cataract Surgery Tonsillectomy Dilation and curettage(DnC)

Other Surgeries:

Medications

Enter medication name and dose to the text box below and press "Add" button or select the "No Medications Taken" button

Medication Name:   Strength:   Select a unit milligrams micrograms grams units

Pharmacy Information

Enter the pharmacy name, address and phone number in the text boxes below and press "Add" button

Pharmacy Name:   Address:   Pharmacy Phone:

Allergies

Enter allergens (including any medications you are allergic to) in the text box below and press the "Add" button.

Medication/Allergen Name:

Family History

Enter a medical condition in the text box below, then select the relative who had the condition from the dropdown menu, and press the "Add" button.

Medical Condition:   Relative that carry this condition Select a Family Member Father Mother Brother Sister Grandmother Grandfather

Social History
Ethnicity:   Select Hispanic or Latino Not Hispanic or Latino Prefer not to answer	Race:   Select American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Prefer not to answer	Preferred Language:
Marital Status:   Select Single Married Divorced Widowed Separated	Use of Alcohol:   Select Never Rarely Moderate Daily	Use of Tobacco:   Select Never Quit Current Smoker
Living Situation:   Select Lives With Family Lives With Friends Lives With Significant Other Lives Alone		Dominant Hand:   Select Right Left Ambidextrous (both)
Occupation:		Place of Birth:

Policy Regarding Notification and Discussion of Medical Information

It is our policy not to release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voice mail or cell phone. When returning calls and an answering machine picks up, we do not leave a message unless it is an appointment reminder. Information also will not be left with an unauthorized person who may answer the phone. Unless there is a serious emergency, we will only discuss your medical care with others according to your instructions.

If you would like to have information released to someone other than yourself, please complete the following:

1. I authorize the medical staff to discuss my medical care with the following people, including myself, and will indicate in writing when I wish to change this authorization:

Name:   Relationship Select Self Father Mother Brother Sister Grandmother Grandfather Wife Husband Boyfriend Girlfriend Son Daughter Friend       Enter a name in the text box to the left, select that person's relationship to you from the dropdown menu, and press the "Add" button.

2. Please list names of authorized people, including yuorself, with whom we may leave messages:

Name:   Relationship Select Self Father Mother Brother Sister Grandmother Grandfather Wife Husband Boyfriend Girlfriend Son Daughter Friend       Enter a name in the text box to the left, select that person's relationship to you from the dropdown menu, and press the "Add" button.

3. With whom may we discuss your financial situation?

Name:   Relationship Select Self Father Mother Brother Sister Grandmother Grandfather Wife Husband Boyfriend Girlfriend Son Daughter Friend       Enter a name in the text box to the left, select that person's relationship to you from the dropdown menu, and press the "Add" button.

4. I authorize the staff to leave medical information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes:

Method of Contact: Select Home Phone Voice Mail Home Fax Cellphone Work Phone Work Voice Mail Work Fax Text Message Email In Person   Device Number or Email:         Select the device from a dropdown, enter appropriate number or email and press the "Add" button.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, , acknowledge receipt this day from QUALITY HEALTH FAMILY MEDICAL CARE of a copy of the "PATIENT PRIVACY NOTIFICATION FORM" of Quality Health Family Medical Care.

Patient/Guardian Signature (Required):