• Embed Doc
  • Copy Link
  • Readcast
  • Collections
  • CommentGo Back
Download
 
 
1
WILLIAM A. SCHROEDER IV, MA, LPC, JUST MIND
Fax: 801.780.8217 Phone: 512.524.7172 Email: ws@justmind.org
REGISTRATION FORM
Today’s Date: PCP:
PATIENT INFORMATION
Patient’s Last Name First Middle Marital StatusMr.Mrs.MissMs.Sgl Mar Div Sep WidIs this your legal name? If not, what is your legal name? Email address Birth Date Age SexYes No M FStreet Address City State ZIP Code Social Security Home Phone No.( )P.O. Box City State ZIP CodeOccupation Employer Employer Phone No.( )Chose Clinic Because/Referred to Clinic by (Please check one box) Dr. Insurance Plan HospitalFamily Friend Close to Home/Work Yellow Pages Other Other Family Members Seen Here
INSURANCE INFORMATION (
PLEASE GIVE A COPY OF YOUR INSURANCE CARD TO OUR OFFICE
)
Person Responsible for Bill Birth Date Address (if different) Home Phone No.Is this person a patient here? Yes No( )Occupation Employer Employer Address Employer Phone No.( )Is this patient covered by insurance? Yes NoPlease indicate primary insurance [
Insurance
] [
Insurance
] [
Insurance
] [
Insurance
] [
Insurance
][
Insurance
] [
Insurance
] [
Insurance
]
Welfare
 
Other 
 
(Please provide coupon)
Subscriber’s Name Subscriber’s Social Security # Birth Date Group # Policy # Co-Payment$Patient’s Relationship to Subscriber Self Spouse Child Other Name of Secondary Insurance (if applicable) Subscriber’s Name Group # Policy #Patient’s Relationship to Subscriber Self Spouse Child Other 
IN CASE OF EMERGENCY
Name of Local Friend or Relative (not living at same address) Relationship to Patient Home Phone No. Work Phone No.( ) ( )The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the doctor or doctor’s office. I understand that I am financiallyresponsible for any balance. I also authorize William Schroeder, JUST MIND or insurance company to release any information required to process my claims.XPATIENT/GUARDIAN SIGNATURE DATE
 
 
2
Original Date:
08/06/2004
Dates Revised:
HEALTH HISTORY QUESTIONNAIRE
 All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name:
(Last, First, M.I.)
 
M
 
F
 
DOB
 
MaritalStatus:
 
Single
 
Partnered
 
Married
 
Separated
 
Divorced
 
Widowed
 
Previous or Referring Doctor:Date of LastPhysical Exam:
 
PERSONAL HEALTH HISTORY
Childhood Illness:
Measles
 
Mumps
 
Rubella
 
Chicken Pox
 
Rheumatic
 
Fever 
Polio
Tetanus PneumoniaHepatitisChicken P
ox
Immunizations andDates:
Influenza
MMR
Measles, Mumps, Rubella
List Any Medical Problems That Other Doctors Have Diagnosed:Surgeries:
Year Reason Hospital
Other Hospitalizations:
Year Reason Hospital
Have you ever had a blood transfusion
?.............................................................................................
Yes
 
No
 
Continued on Next Page / Back Side
 
 
3
List Your Prescribed Drugs and Over-the-Counter Drugs, Such as Vitamins and Inhalers:
Name of Drug Strength Frequency Taken
Allergies to Medications:
Name of Drug Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
Exercise:
Sedentary (No exercise) Mild Exercise (i.e., climb stairs, walk 3 blocks, golf)Occasional Vigorous Exercise (i.e., work or recreation less than 4x / week for 30 min.)Regular Vigorous Exercise (i.e., work or recreation 4x / week for 30 minutes)
 
Diet:
 Are you dieting?............................................................................................................ Yes NoIf yes, are you on a physician prescribed medical diet? ............................................ Yes NoNumber of meals you eat in an average day?Rank Salt Intake Hi Med Low Rank Fat Intake Hi Med Low
Caffeine:
None Coffee Tea Cola # of Cups/Cans Per Day?
 All questions contained in this questionnaire are optional and will be kept strictly confidential.
Alcohol:
Do you drink alcohol? ............................................................................................... Yes NoIf yes, what kind?_____________________ How many drinks per week? _____  Are you concerned about the amount you drink? ................................................... Yes NoHave you considered stopping? ............................................................................... Yes NoHave you ever experienced blackouts? ................................................................... Yes No Are you prone to “binge” drinking? ........................................................................... Yes NoDo you drive after drinking? ...................................................................................... Yes No
Tobacco:
Do you use tobacco?
.......................................................................................
Yes
 
No
 
Cigarettes - Packs/day Chew - #/day Pipe - #/dayCigars - #/day # of Years or Year Quit
Drugs:
Do you currently use recreational or street drugs? ................................................. Yes NoHave you ever given yourself street drugs with a needle? ..................................... Yes No
Continued on Next Page / Back Side
of 00

Leave a Comment

You must be to leave a comment.
Submit
Characters: ...
You must be to leave a comment.
Submit
Characters: ...