Dartmouth Dermatology Associates - Patient Forms - Dartmouth Dermatology Associates

PATIENT REGISTRATION FORM

PATIENT INFORMATION:

Last Name ______________________ First Name ________________________________________
Social Security # _____-____-______ Sex _______
Address_________________________________P.O. Box __________________
City ________________________ State ____ Zip________
Telephone____-____-____(H)____-____-____(W)___-___-___DOB____/____/____ Marital Status_____
E-Mail __________________________

WORK/SCHOOL INFORMATION:

Employer/School _______________________________Employer Name ______________________________
Employer Address ________________________________
Primary Care Physician _____________________________ Primary Care Physician Phone ___-___-___
Pharmacy _______________________ Pharmacy Location _________________________
Pharmacy Phone ___-___-___

GUARANTOR INFORMATION:

Last Name _______________________________First Name _______________________________
Social Security # ___-___-___ D.O.B. _________ Address ____________________________
City__________________ State____Zip _______
Phone ___-___-___(H) ___-___-___ (W) ___-___-___ (C)

INSURANCE INFORMATION:

Primary Insurance__________________________ID #______________________ Co-Pay ______________
Secondary Insurance__________________________ID #______________________ Co-Pay ______________

PRESENT ILLNESS:

What is the problem your experiencing? ______________________________
Location? ____________________
How long has it been going on? _____________________
What are your symptoms?___________________________________
Have you had any treatment for this condition?_______________________________
What medications have you used for this condition?________________________________
Who referred you to this office? _______________________
Have you had any recent bloodwork done?____________

CURRENT MEDICATIONS:

(including over the counter ie; Aspirin, Vitamins, etc.)
____________________ ____________________ ____________________
____________________ ____________________ ____________________

ALLERGIES:
__________________________________________________

HOSPITALIZATIONS:

Year-------Reason for hospitalization-------------Hospital
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

SOCIAL HISTORY:

# Pregnancies_____-----------Male_____Female____

FAMILY HISTORY:

_____Heart Disease_____Diabetes_____Cancer_____Melanoma/Skin Cancer
_____Allergies_____Eczema_____Psoriasis_____Asthma

Weight ______lbs. / Height______In..

PAST MEDICAL HISTORY:

Alcohol-------------------Y N
Anemia-------------------Y N
Arthritis------------------Y N
Asthma/Hayfever-------Y N
Cancer,tumor------------Y N
Diabetes------------------Y N
Drug abuse---------------Y N
Depression---------------Y N
Eczema, hives, rashes---Y N
Epilepsy------------------Y N
Headaches/Migraines---Y N
Heart Disease------------Y N
High Blood Pressure----Y N
Liver disease, hepatitis, yellow jaundice-----Y N
Lung disease, Tuberculosis.-------Y N
Nervous breakdown/mental illness-----------Y N
Phlebitis------------------Y N
Stroke---------------------Y N
Suicide attempt----------Y N
Thyroid disease----------Y N
Tobacco use--------------Y N
Transfusions--------------Y N
Ulcer in stomach---------Y N
Uncontrolled bleeding---Y N
Venereal disease----------Y N

Patient Signature__________________________________________