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

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    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