New Patients Medical Registration
THIS REGISTRATION IS ONLY FOR GONZAGA FAMILY HEALTH PRIMARY CARE. All patients are required to fill out a Medical registration form. This should take approximately 15-20 minutes to complete.
Patient Name
*
First Name
Middle Name
Last Name
Suffix
Patient Sex
*
Male
Female
Transgender
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Social Security Number (no dashes, PLEASE GIVE FULL 9 DIGIT NUMBER)
*
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Contact Number
*
Best e-mail to reach you
*
example@example.com
Do you consent to receiving messages from our office at the email address listed above?
*
Yes
No
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Some more personal information we need
Your Employment Status
*
Employed part time
Unemployed
Self-employed
Employed full time
Other
If you are employed, please provide your work phone number
-
Area Code
Phone Number
Are you of Hispanic/Latino decent?
*
Yes
No
Race:
Who is your current primary care provider? If you don't have one, just put "N/A"
Marital Status
*
Married
Divorced
Widowed
Domestic Partnership
Single
Other
Name of your spouse or significant other. If you are single, you can skip this.
First Name
Last Name
Phone number of your spouse or significant other.
-
Area Code
Phone Number
Emergency Contact
*
First Name
Last Name
Phone Number of Emergency Contact
*
-
Area Code
Phone Number
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Insurance Information
** PLEASE PROVIDE US WITH COMPLETE INSURANCE INFORMATION. IF WE DO NOT OBTAIN ALL INSURANCE INFORMATION WE WILL BE UNABLE TO SCHEDULE YOU FOR AN APPOINTMENT AT OUR PRACTICE. **
Will you be using insurance, or will you be paying out-of-pocket?
*
Insurance
Out of Pocket
Primary Insurance Name
Primary Insurance Member ID: (IF YOU HAVE INSURANCE PLEASE PROVIDE THE ID NUMBER!!)
Group ID:
Address where insurance claims are to be sent (located on the back of the card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Policy Holder
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Name (if none, leave and all the rest blank)
Secondary Insurance Member ID:
Group ID:
Address for secondary where insurance claims are to be sent (located on the back of the card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Policy Holder (only if different than primary)
First Name
Last Name
Date of Birth of Secondary Insurance Policy Holder (only if different than primary)
-
Month
-
Day
Year
Date
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Pharmacy and Medications
Please select the best option...
*
I have a pharmacy that I use.
I don't have a pharmacy.
I might be changing my pharmacy.
Pharmacy Name
Pharmacy Location and Phone Number
Preferred Lab
Lab Location
Preferred Imaging Facility
Imaging Facility Location
If the patient is on any current Medication please list them here along with the dosage. This also includes supplements and Vitamins. If they are not currently on anything put N/A
*
If none put N/A
Do you have any allergies to medications? If so, list the medication and the type of reaction you have. If you do not have any know allergies put N/A
*
If none put N/A
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Social and Surgical History
Are you able to care for yourself?
*
Yes
No
Do you have an Advance Directive?
*
Yes
No
Do you drink alcohol?
*
Yes
No
If "YES" how many drinks do you consume in a week?
Do you have a history of substance abuse?
*
Yes
No
If "YES" please write what substances you have abused:
Do you smoke?
*
Yes
No
If "YES" how many cigarettes do you smoke per day?
E-cigarette/Vape status
Yes
No
If "YES" How much, how often, and what type?
Do you use chewing tobacco?
*
Yes
No
If "YES" How often do you chew and how much per day?
Please list all past surgeries, the hospital that performed the surgeries, and the approximate date. If you don't have any past surgeries to report, please write "N/A"
*
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Gynecological History
The approximate date of your last pap smear was
-
Month
-
Day
Year
Date
If you are post-menopausal, what age were you at the onset of menopause?
What was the date of your last mammogram? If none, leave blank.
-
Month
-
Day
Year
Date
What was the date of your last colonoscopy? If none, leave blank.
-
Month
-
Day
Year
Date
How old were you at menarche (when you got your first period)?
What was the date of your last LMP (Period)?
Flow
Duration of flow (days)?
Frequency of cycle
Did you ever receive the HPV vaccine?
*
Yes
No
I don't know.
Are you sexually active?
*
Yes
No
Do you have STI or a sexually transmitted disease?
*
Yes
No
Do you have any sexual issues you would like to discuss with the provider?
*
Yes
No
Do you currently use birth control?
*
Yes
No
If "YES" What method of birth control do you use?
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Obstetrics History
If applicable, If not skip to the next section.
Did you ever give birth?
Yes
No
If "YES" please give the number of living children...
Have you ever had a miscarriage (spontaneous abortion)?
Yes
No
If "YES" please give the number of miscarriages...
Have you ever had an induced abortion?
Yes
No
If "YES" please give the number of induced abortions...
Have you ever experienced an ectopic pregnancy?
Yes
No
Did you ever have a stillborn?
Yes
No
Did you experience preterm labor?
Yes
No
Did you ever have abnormal bleeding?
Yes
No
Did you ever have an abnormal ultrasound?
Yes
No
Did you ever have a rupture of a membrane?
Yes
No
Were there any maternal infections?
Yes
No
I don't know
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Medical History
These condition are concerning the patient ONLY! Please put family medical history in its respected area!
CONDITIONS
ADD/ADHD
AIDS/HIV
Abuse/domestic violence
Allergies/hay fever
Anemia
Anesthesia Complications
Anxiety Disorder
Arthritis
Asthma
Autism spectrum disorder
CONDITIONS Continued...
Birth defects or inherited disease
Bladder or kidney problems
Blood diseases
History of blood transfusion
Breast cancer
Breast problem
COPD
Other type of cancer
Chicken Pox
CONDITIONS Continued...
Chronic ear infections
Congestive heart failure
Constipation outside of typical
Coronary artery disease
Depression
Developmental or behavioral disorders
Diabetes
Difficulty swallowing
Diverticulitis
CONDITIONS Continued...
Ear or hearing problems
Eating disorders
Eczema
Endometriosis
Fibromyalgia
GI problems (stomach)
Gout
Head injury or concussion
Frequent headaches
Heart problems
CONDITIONS Continued...YOU'RE ALMOST DONE!
Hepatitis
High cholesterol
Hypertension
Hyperthyroidism
Hypothyroidism
Infertility
Kidney disease
Kidney stones
Liver disease
Lung disease
Mental disorder
Muscle, joint, or bone problems
CONDITIONS Continued...The last batch
Obesity
Osteoporosis
Ovarian cancer
Polyps
Pulmonary embolism
Reflux/GERD
Seizures or epilepsy
Skin problems
Stroke
Thyroid Problems
Turberculosis
Varicosites
Vision or eye problems
Please list any medical history of immediate blood relatives of the patient (Mother, Father, Material & Paternal Grandparents, Brother, Sister)
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One Last Thing
We are always trying to improve the patient experience. Please rate your experience.
Overall, how was your experience filling out this form compared to other online forms?
*
1
2
3
4
5
6
7
Worst
Best
1 is Worst, 7 is Best
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