REGISTRATION AND HISTORY RECORD
First Last
Name: 
Sex: 
Male   Female  
Birth Date: 
/ /  
Address: 
City: 
State: 
  Zip: 
Home Phone: 
( )   – 
Work Phone: 
( )   –   Ext.
Employed By: 
Email Address: 
Social Security Number: 
 –   – 
Drivers License Number: 
Marital Status:   Married   Single   Widowed   Divorced  
Person to contact in case of emergency: 
Relationship to you: 
Their Home Phone: 
( )   – 
Their Work Phone: 
( )   –   Ext.
Medical Insurance Information ( We will need to copy your insurance cards each time you visit)
Person to receive bills
(If same as above skip): 
Relationship to you: 
Address: 
City: 
State: 
  Zip: 
Their Home Phone: 
( )   – 
Their Work Phone: 
( )   –   Ext.
Their Social Security Number: 
 –   – 
Their Birth Date: 
/ /  

I, the undersigned, have insurance coverage with and assign directly to Primary Care Group all surgical and/or medical benefits for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.

First Last
Type your name: 
Date: 

MEDICARE PATIENTS ONLY: PLEASE SIGN FOR LIFETIME AUTHORIZATION

I authorize Primary Care Group to release the the Health Care Financing Administration and Social Security Administration or its intermediaries any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to Primary Care Group or the party who accepts assignment.
First Last
Type your name: 
Date: 
YOUR FAMILY'S HEALTH
    First Name Birth Year Health Good Health Poor Died at Age Cause of death
Father
Mother
Brother
Brother
Sister
Sister
Spouse
Children
Children
HABITS
Caffeine   Yes   No       Drugs   Yes   No  
Smoking   Yes   No       Packs Per 
Day: 		     Age started: 
Alcohol   Yes   No       How much? 
Herbs/Vitamins   Yes   No       List: 
HEALTH CARE PROVIDERS - Who else have you seen for your health care in the past 5 years?
Year Name of Doctor/Other Provider Location: City, State Primary Problems Cared For
HOSPITILIZATION - List serious illnesses and injuries or operations and approximate year. EXCLUDE NORMAL PREGNANCIES.
Year Serious illness,
injury or operation		 Name of Hospital City and State
ILLNESSES - Check where you or your family have had the following illnesses or problems:
You      Your Family       
Yes   No        Yes   No        Alcoholism
Yes   No        Yes   No        Anemia
Yes   No        Yes   No        Arthritis
Yes   No        Yes   No        Asthma
Yes   No        Yes   No        Blood Clots
Yes   No        Yes   No        Cancer, Tumor
Yes   No        Yes   No        Colitis / Stomach Problems
Yes   No        Yes   No        Diabetes
Yes   No        Yes   No        Drug Abuse
Yes   No        Yes   No        Depression / Anxiety
Yes   No        Yes   No        Epilepsy
Yes   No        Yes   No        Glaucoma
Yes   No        Yes   No        Headache
Yes   No        Yes   No        Heart Disease
Yes   No        Yes   No        Heart Murmur
Yes   No        Yes   No        High Blood Pressure
Yes   No        Yes   No        Kidney / Bladder Problems
Yes   No        Yes   No        Liver Disease, Hepatitis, Yellow Jaundice
Yes   No        Yes   No        Low Back Pain
Yes   No        Yes   No        Lunk Disease, Tuberculosis
Yes   No        Yes   No        Stroke
Yes   No        Yes   No        Suicide Attempt
Yes   No        Yes   No        Thyroid Disease
Yes   No        Yes   No        Uncontrolled Bleeding

Other Illnesses:

DRUG and / or OTHER ALLERGIES - List those to which you are allergic:

 
First Last
Type your name: 
Date: