Patient Registration
Identity Information
Education Level
Are there any vision problems that affect your communication?
Are there any hearing problems that affect your communication?
Are there any limitations to understanding or following instructions (either written or verbal)?
Current Living Situation
(Check all that apply)
Smoking/Tobacco Use
Alcohol
Recreational Drug Use
Are you sexually active?
Are there any personal problems or concerns at home, work, or school you would like to discuss?
Are there any cultural or religious concerns you have related to our delivery of care?
Are there any financial issues that directly impact your ability to manage your health?
How often do you get the social and emotional support you need?
Father
Mother
Siblings
Medications
List all medications you take, including over-the-counter medications and vitamins. Include specific doses and when taken. If you don't know, please call your pharmacist to confirm.
Personal Medical History
Please circle all that apply
Last Menstrual Period
Colonoscopy
Mammogram
Dexa/Bone Density
Pap
Surgical History
Please list all prior sugeries and approximate dates performed
Signature