PATIENT INFORMATION - Secure Form

Patient Name Date of Birth: Age: Sex: M F
Last, First Middle

Address:
P.O. Box and Street Address, City, State, Zip

Marital Status (check one): Minor Single Married Divorced Widowed Separated

Social Security Number: Home Telephone: Work Telephone:

Driver's License #: State Issued: E-Mail address:

Patient/Parent's Employer Name & Address:

Emergency Contact Information

Address:
P.O. Box and Street Address, City, State, Zip

Home Telephone: Work Telephone:

Responsible Party Information:

Address:
P.O. Box and Street Address, City, State, Zip

Social Security Number: Home Telephone: Work Telephone:

Driver's License #: State Issued:

PERSONAL HEALTH HISTORY

Please check illnesses or symptoms that you presently have or have had in the past.

HEAD, EYES, EARS, NOSE, THROAT BLURRED VISION DIZZINESS DOUBLE VISION FREQUENT HEADACHES MIGRAINE HEADACHES SINUS PROBLEMS PAIN BEHIND EYES FAINTING SPELLS UNCONSCIOUS SPELLS WEAR GLASSES EARACHES DRAINAGE FROM EARS DECREASE HEARING RINGING IN EARS NOSEBLEEDS RECURRENT HEAD COLDS STRANGE TASTE OR LOSS OF TASTE STRANGE PERSISTENT ODORS PERSISTENT HOARSENESS URINARY DIFFICULTY STARTING STREAM PAIN WITH URINATION URINATE MORE OR LESS THAN USUAL LOSE URINE WITH COUGH/SNEEZE DISCHARGE BLOOD IN URINE KIDNEY STONES MUSCULOSKELETAL JOINT PAIN RECURRENT BACK PAIN SWELLING OF JOINTS REDNESS OR WARMTH IN JOINTS TINGLING/WEAKNESS IN HANDS/FEET MUSCLE SPASMS BROKEN BONES TREMBLING OF ANY EXTREMITY ENDOCRINE THYROID PROBLEMS GROWTH IN NECK OR THROAT BRITTLE NAILS DRYNESS OF SKIN OR RASHES INABILITY TO STAND COLD OR HEAT CHANGE IN HAIR TEXTURE DIABETES ABNORMAL WEIGHT GAIN OR LOSS TIREDNESS WITHOUT REASON BRUISE EASILY

CARDIAC ANGINA CHEST PAIN HIGH BLOOD PRESSURE PALPITATIONS/HEART FLUTTERING HEART ATTACK HIGH CHOLESTEROL RESPIRATORY ASTHMA OR HAY FEVER CHRONIC COUGH COUGHED UP BLOOD NIGHT SWEATS SHORTNESS OF BREATH PNEUMONIA INFLUENZA PLEURISY GASTROINTESTINAL DIFFICULTY SWALLOWING RECURRENT SORE THROAT BLADDER DISEASE ENLARGED GLANDS SORES IN MOUTH SORE OR BLEEDING GUMS BELCHING OR HEARTBURN NAUSEA OR VOMITING VOMITED BLOOD AVOID CERTAIN FOODS ABDOMINAL CRAMPING CHANGE IN BOWELS BLOOD IN STOOLS RECTAL PAIN GALLBLADDER DISEASE HEMORRHOIDS COLITIS WOMEN ONLY AGE OF ONSET OF PERIODS IRREGULAR PERIODS HEAVY PERIODS PAINFUL PERIODS VAGINAL DISCHARGE/BURNING COMPLICATIONS WITH PREGNANCY ABNORMAL PAP SMEAR SEXUALLY TRANSMITTED DISEASE MEN ONLY RASH, SORES ON PENIS OR DISCHARGE DISCHARGE FROM PENIS IMPOTENCE SEXUALLY TRANSMITTED DISEASE

By clicking submit, I authorize the release of any medical information necessary to process my insurance claim and request payment of government benefits either to myself or to the party who accepts assignment. I also authorize payment of medical benefits to physician/provider for services rendered pursuant to filing insurance claim. I authorize representatives of Grayson Highlands Family Medicine to leave messages with family members or messages on home answering machines concerning lab results and appointment reminders. I authorize the collection of blood samples for testing for Hepatitis, HIV and other bloodborne pathogens in the event of an accidental needle stick injury.