Family Medicine Clinic at Plano PATIENT DEMOGRAPHIC INFORMATION FORM Physician: Punam Patil HOW DID YOU HEAR ABOUT OUR CLINIC? REFERRING PHYSICIAN’S NUMBER PATIENT’S FULL NAME ADDRESS MAIDEN NAME APT# CITY  GENDER:M F STATE DATE OF BIRTH / / Asian Black or African American Native Hawaiian or Other Pacific Islander White Declined to Specify ETHNICITY HISPANIC OR LATINO NON-HISPANIC OR LATINO Declined to Specify PRIMARY CONTACT NUMBER - CELL ( ) WORK ( ) MARITAL STATUS SINGLEDIVORCED MARRIED WIDOWED OTHER PREFERRED LANGUAGE SECONDARY NUMBER RELATIONSHIP DATE OF BIRTH PHONE ( PRIMARY INSURANCE COVERAGE INSURED’S DATE OF BIRTH INSURANCE COMPANY NAME OF INSURED INSURED’S EMPLOYER INSURANCE CLAIM’S ADDRESS CITY INSURANCE COMPANY NAME OF INSURED INSURED’S EMPLOYER INSURANCE CLAIM’S ADDRESS CITY ) ADDRESS EMERGENCY CONTACT POLICY NUMBER ZIP PATIENT’S SOCIAL SECURITY - RACE American Indian or Alaska Native EMAIL PATIENT’S EMPLOYER EMPLOYER’S ADDRESS SPOUSE/GUARDIAN’S NAME EMPLOYER PHONE ( SELF SPOUSE COPAY AMOUNT - PARENT OTHER INSURANCE PHONE ( STATE ) ) - ZIP GROUP INSURED’S NUMBER SOCIAL SECURITY SECONDARY INSURANCE COVERAGE INSURED’S DATE OF BIRTH SELF PARENT SPOUSE OTHER COPAY AMOUNT INSURANCE PHONE ( STATE POLICY GROUP NUMBER NUMBER ANY OTHER YES COMPANY INSURANCE COVERAGE NO NAME INSURANCE AUTHORIZATION AND ASSIGNMENT ) - ZIP INSURED’S SOCIAL SECURITY PHONE ( ) - I authorize Medicine Clinic at Plano to release to my insurance carrier and/or their agents any information necessary to determine benefits payable for related services. I authorize the payment of medical benefits to Centennial Family Medicine at East Frisco Clinic. I understand that I am ultimately responsible for all services whether covered by insurance or not. I also authorize my physician, based on his/her discretion, to access my chart for utilization management review. DATE: SIGNATURE: ADULT PATIENT INFORMATION WE STRIVE TO KEEP ALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT. It may be sent to consultants, if referred. NAME: DATE: LAST FIRST DATE OF BIRTH: / / M.I. AGE: GENDER: M / F PREFERRED PHARMACY: NAME PHONE NUMBER NAME PHONE NUMBER PREVIOUS PHYSICIAN: MEDICATIONS: Name Ex. (Please include all vitamins and herbal(s)) Advil Dosage Frequency 200mg 3x daily MEDICAL CONDITION(S)/HOSPITALIZATIONS:(Examples: diabetes, high blood pressure, asthma, etc.) ALLERGIES:(Medications, food, environmental) Are you participating in ANY clinic research/trials? Y / N SURGERIES: (Examples: Tonsillectomy, TYPE OF SURGERY Have you had a colonoscopy? Gallbladder, Hernia Repair, etc) YEAR Where? WOMEN’S HEALTH: LAST MENSTRUAL CYCLE: PREGNANCIES: MISCARRIAGES: CHILDREN: LAST PAP SMEAR: EVER HAD AN ABNORMAL ONE? LAST MAMMOGRAM: Where? LAST BONE DENSITY: Where? MEN’S HEALTH: LAST TESTICULAR EXAM: LAST PROSTATE EXAM: Family Medicine Clinic at Plano -Adult Information Sheet Rev. 06/14 ADULT PATIENT INFORMATION NAME: DATE: LAST FIRST / / M.I. PLEASE SHARE YOUR SHOT RECORD WITH US!! LAST TETANUS SHOT: LAST FLU SHOT: RECEIVED ALL 3 DOSES OF HEPATITIS B VACCINE? Y / N HAD CHICKEN POX OR THE VARICELLA VACCINE? Y / N Date or approximate if known): / / OCCUPATION(S): MARITAL STATUS: Single Married Divorced Separated Widowed SEXUAL ORIENTATION: TOBACCO IF TOBACCO IF USER YES, USER YES, Heterosexual Homosexual Bisexual Trans-sexual CURRENTLY? Y / N # OF PACKS PER DAY IN THE PAST? Y / N WHEN DID YOU QUIT? WHEN DID YOU START? ALCOHOL USER? Y / N ALCOHOL USER IN THE PAST? Y / N NUMBER OF DRINKS PER DAY? TYPE OF ALCOHOL? (ex. Beer, vodka, cocktails) DRUG USER CURRENTLY? Y / N DRUG USER IN THE PAST? Y / N TYPE OF DRUGS? (EX. Marijuana, cocaine, etc) HAVE YOU EVER INJECTED YOURSELF WITH DRUGS? Y / N CAFFEINE USER? Y / N HOW MANY CUPS OF COFFEE/TEA PER DAY? NUMBER OF SODAS PER DAY? HOW WOULD YOU CLASSIFY YOUR NUTRITION? Excellent Good Fair  Bad EXERCISE REGULARLY? Y / N TYPE: TIMES PER WEEK: HOW LONG? (MINUTES) DO YOU WEAR YOUR SEATBELT? Y / N DO YOU CONSENT TO TRANSFUSION IF REQUIRED? Y / N FAMILY HISTORY: (Please list medical conditions that run in your family. Ex. Heart attack, stroke, high cholesterol, diabetes, etc.) CONDITION/AGE OF ONSET FATHER: MOTHER: BROTHER(S): SISTER(S): GRANDPARENTS: PATERNAL: MATERNAL: LIVING Y / N Y / N Y / N Y / N Y / N Y / N Family Medicine Clinic at Plano -Adult Information Sheet Rev. 06/14