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Last Name

_____________________

First Name

_______________

Middle Name

____________

Address

Number and Street ________________________________________

City, State, Zip Code ________________________________________

Phone Number

area code_____/_____-_________

e-mail

____________________________

Date of Birth 

month_____/day______/year_____

 

Do you have medical insurance?

Insurance Company________________________

Policy No. _______________________________

S. S. Number

_______/____/___________

Are you covered by Medicare? 

yes __________

 no  __________

Are you covered by Medicaid? 

yes __________

 no  __________

Health  History

Check all applicable    

  1. ___heart disease
  2. ___frequent chronic headaches
  3. ___arthritis
  4. ___diabetes
  5. ___full-term pregnancies 
  6. ___miscarriages/abortions
  7. ___HIV infection
  8. ___broken bones
  9. ___childhood illnesses
  1. ___asthma
  2. ___tuberculosis
  3. ___pneumonia
  4. ___addiction 
  5. ___frequent colds
  6. ___fainting spells
  7. ___chronic fatigue
  8. ___weight loss/gain
  9. ___severe depression
  10. ___allergies

History of Hospitalizations

Please list your most recent hospitalization first.

List all medications you are currently taking.

 (1) Reason for hospitalization:_____________

from___/___/___to__/___/___                      

(2) Reason for hospitalization:______________

from ___/___/___ to ___/ ___/___

(3) Reason for hospitalization:______________

from ___/___/___ to ___/ 

  1. ________________
  2. ________________
  3. ________________
  4. ________________

Signature_____________________________  Date: month_______/day_______/year_______