New Patient Registration Name * First Name Last Name Preferred First Name (if different than above) Have you ever been known by another last name (ex. maiden name)? If so, what? Date of Birth * MM DD YYYY Social Security Number * Email * Phone * (###) ### #### Cell (###) ### #### Consent to Text * Yes No Consent to Automated Calls * This is used for appointment reminders. Yes No Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Race * White Black or African American American Indian or Alaska Native Asian Pacific Islander or Native Hawaiian Other Sexual Orientation * Straight or heterosexual Lesbian, gay, or homosexual Bisexual Something else Don't know Choose not to dislose Gender Identity * Identifies as male Identifies as female Transgender Male/Female-to-Male (FTM) Transgender Female/Male-to-Female (MTF) Gender non-conforming (neither exclusively male nor female) Additional gender category /other Choose not to disclose Assigned Sex at Birth * Male Female Choose not to disclose Unknown Preferred Pronouns * He/him She/her They/them Other not listed Choose not to disclose Marital Status * Single Married Divorced Partner Separated Widowed If you have children, how many? Employer Name Employer Phone (###) ### #### Usual Occupation Usual Industry Primary Insurance * Policy Number * Group Number Policy Holder Name * Policy Holder Social Security Number (if different than above) Relationship To Policy Holder Secondary Insurance Policy Holder Name (if different than above) Policy Holder Date of Birth MM DD YYYY Policy Number Group Number Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship To Patient * Is it OK to discuss your medical care with your emergency contact? * Yes No Is there another person you would give permission for us to discuss your medical care? Next Of Kin * First Name Last Name Next Of Kin Phone * (###) ### #### Relationship To Patient * Preferred Local Pharmacy and Location * Preferred Mail Order Pharmacy Medications * Please list all medications/supplements and include dose and instructions. Please list any medical providers (past or present): * How did you hear about Jessica? * Please list any prior surgeries: Do you have any concerns or wellness goals that you would like addressed? * Please list any symptoms you are currently experiencing: * What is your assessment of your general level of health? * Healthy overall Chronically ill Are you experiencing any of the following symptoms? Check all that apply. Constitutional Recent weight gain Recent weight loss Fever Night sweats Eyes Vision changes Eye disease/injury Wear glasses/contact lenses Ears, Nose, Mouth, Throat Difficulty hearing Nose problems Sinus problems Sore throat Snoring Mouth problems Dental problems Dentures/dental implants Ringing in the ears Cardiovascular Chest pain Arm pain on exertion Shortness of breath when walking Shortness of breath when laying down Lightheaded on standing Palpitations Known heart murmur Ankle swelling Respiratory Cough Wheezing Shortness of breath Coughing up blood Sleep apnea Gastrointestinal Abdominal pain Nausea Vomiting Constipation Diarrhea Change of appetite Genitourinary Difficulty urinating Increased frequency Urinary loss of control Incomplete emptying Muscoloskeletal Muscle aches Muscle weakness Joint pain Back pain Swelling in the extremities Neck pain Difficulty walking Osteoporosis Fractures Skin Abnormal mole Rash Non-healing areas Psoriasis Change in skin color Breast lump Growths/lesions Neurologic Weakness Numbness Seizures Dizziness Frequent or severe headaches Migraines Tremor Psychiatric Depression Sleep disturbances Feeling unsafe in a relationship Anxiety Hallucinations Suicidal thoughts Memory loss Dementia Endocrine Fatigue Increased thirst Hair loss Hematologic/Lymphatic Swollen glands Excessive bleeding Anemia Allergy/Immunologic Runny nose Sinus pressure Itching Hives Frequent sneezing PHQ-9 Depression Screening Over the past 2 weeks, how often have you been bothered by the following problems? Little interest or pleasure in doing things: * Not at all Several days More than half the days Nearly every day Feeling down, depressed or hopeless: * Not at all Several days More than half the days Nearly every day Trouble falling asleep, staying asleep or sleeping too much: * Not at all Several days More than half the days Nearly every day Feeling tired or having little energy: * Not at all Several days More than half the days Nearly every day Poor appetite or overeating: * Not at all Several days More than half the days Nearly every day Feeling bad about yourself - or that you are a failure or have let yourself or your family down: * Not at all Several days More than half the days Nearly every day Trouble concentrating on things, such as reading the newspaper or watching TV: * Not at all Several days More than half the days Nearly every day Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual: * Not at all Several days More than half the days Nearly every day Thoughts that you would be better off dead or of hurting yourself in some way: * Not at all Several days More than half the days Nearly every day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? * Not difficult at all Somewhat difficult Very difficult Extremely difficult GAD-7 Anxiety Screening Over the past 2 weeks, how often have you been bothered by the following problems? Feeling nervous, anxious, or on edge: * Not at all Several days More than half the days Nearly every day Not being able to stop or control worrying: * Not at all Several days More than half the days Nearly every day Worrying too much about different things: * Not at all Several days More than half the days Nearly every day Trouble relaxing: * Not at all Several days More than half the days Nearly every day Being so restless that it's hard to sit still: * Not at all Several days More than half the days Nearly every day Becoming easily annoyed or irritable: * Not at all Several days More than half the days Nearly every day Feeling afraid, as if something awful might happen: * Not at all Several days More than half the days Nearly every day
