Paul R. Young, M.D. PLLC | Adult Registration

Today’s Date: YYYY-MM-DD format

GENERAL INFORMATION

First Name:


MI:

Last Name:

Social Security Number:


Date of Birth: YYYY-MM-DD format


Address 1:

Address 2:

City:

State:

Zipcode:

Phone Numbers

Home:

Cell:

Work:

E-mail address

If we need to contact you, which is the preferred number?



Can we leave a message at this number on the answering machine?



Are there other members of the household that we may leave the message with regarding your health matters?




If so whom?


E-mail address (Required Field)



Occupation:

Employer:

Preferred Pharmacy

Pharmacy Name:

Pharmacy Address:

Government regulations require we ask for the following identifying information.

Gender:

Race:

Other Race:

Ethnicity:

Primary Preferred Language:

Other Language:

How did you hear about our practice?



Physician Referral
Doctor’s Name:


Friends / Family
Whom may we thank?

Web SearchSocial Media
Other:


Primary care Doctor’s Name:

ADULT REVIEW OF SYSTEMS

Ear, Nose and Throat:




PAST MEDICAL HISTORY

(Please check the symptoms below to indicate.)
Indicate if you have any of the medical problems listed below and add any additional problems not covered in the space provided.



If you have a cancer history, please fill out below:


Other Medical History:


SOCIAL HISTORY:
Do you smoke?



Former smoking date:



Do you drink alcohol?



If yes, how much?



Do you use recreational drugs (Marijuana, Cocaine, Heroin, etc.)?

FAMILY HISTORY:

Do any of these diseases run in your family:

Diabetes


Heart Disease


Anesthesia Complications


Cancer


Bleeding Disorders

Others

PAST SURGICAL HISTORY

Please list previous surgeries:



CURRENT MEDICATIONS

Please indicate doses and how often you take.



ALLERGIES TO MEDICATIONS