Would you like to save time at your visit?
Each new patient will need to have a registration and health information disclosure
form, which is included in the New Patient Packet.
• Print the form and fill it out (DO NOT SIGN or DATE the form.)
On the day of your appointment bring all printed forms and give them to the
receptionist when you come in for your appointment. You will be asked to sign
and date them in our office.
Or
• Fill out the PDF form on-line print at home and submit all paperwork by mailing
to our office. (DO NOT SIGN or DATE the form.) You will be asked to sign and
date them in our office the day of your appointment.
Please arrive 15 minutes early and bring all forms, insurance cards, form of
payment to cover cost of your deductible, and medications with you.
Note: We will not accept any forms that have be signed or dated prior to
your office visit. It is very important that we maintain up-to-date information.
Harris Medical Group is proud to offer our patients a variety of services, in order to
deliver the best care for you and communicate with you regarding appointments it
is necessary that we keep all of your information up-to-date. To help us serve you
better we will ask that you verify your contact and insurance information at every
appointment check-in. Additional information is also available once you are signed
up for the Patient Portal.
Registration Form
Patient Information:
Last Name: ____________________
First Name: _____________________
SSN: _____-_____-____
Sex: (Check)
M
F
MI: ___
Suffix: _____
Birth Date: _____/_____/____
Mailing Address: ________________________ City: _______________ State: ____ Zip: _________
Home Tel: _____-_____-_____ Cell Phone: _____-_____-_____
Usual Doctor:
___________
Advanced Directive:
Y
N
Work Phone: _____-_____-_____
Primary Care Doctor: ___________
Referring Doctor: ___________
Pharmacy Name/Phone Number: ________________________________
Employer/School (Daycare): ___________________ Grade: ________ Email: ___________________
Skilled Nursing Facility: ________________________________________________________________
Ethnicity:
Preferred Language:
White/Caucasian
Black/African American
Race:
Latino or Hispanic
English
Single
Asian Hawaiian
American Indian/Alaska Native
Not Hispanic
Spanish
Divorced
Pacific Islander
More than 1 race
Prefer not to answer
Other
Widowed
Prefer not to answer
Account Information:
Marital Status:
Married
Separated
(Patient Information, Emergency Contact, Personal Representatives)
Please list any individuals (family, friends, etc) with whom we may discuss your medical care or leave.
Last Name, First Name
Address
City State Zip
Home / Cell Phone Numbers
Relationship
___________________________________________________________________________________
___________________________________________________________________________________
Please circle all phones where we may leave voicemail regarding your care:
Home
Cell
Work
Family Members Cared for in Practice: ____________________________________________________
Guardian/Guarantor Information:
If minor, please list who the child lives with.
Last Name: _____________________ First Name: _____________________ MI: ___
Address: _____________________________
City: _______________ State: ____ Zip: _________
Home Tel: _____-_____-_____ Cell Phone: _____-_____-_____
SSN: _____-_____-____
Suffix: _____
Sex: (Check)
M
F
Work Phone: _____-_____-_____
Birth Date: _____/_____/____
Employer: ___________________ Relationship: __________________ Email: ___________________
Policy Information:
Is this Workers Comp: (Circle)
Yes
No
Primary Insurance Company: ________________________________________________________
Policy Holder Full Name: __________________ SSN: ____-____-____ Birth Date: _____/_____/____
Relationship to Patient: ____________
Member ID: _______________
Group ID: ______________
Secondary Insurance Company: ______________________________________________________
Policy Holder Full Name: __________________ SSN: ____-____-____ Birth Date: _____/_____/____
Relationship to Patient: ____________
Member ID: _______________
Group ID: ______________
__________
Initial
_________
Date
Registration Form
Harris Medical Group
*Please make sure that the receptionist copies your insurance card and drivers license*
Prescriptions:
We ask that you bring all of your medication bottles with you at the time of each visit. If you need a refill, please call
your pharmacy and ask them to fax a request. Our providers will review the request and refill by fax or notify you to
make an appointment if necessary. We ask for up to 3 business days to refill all medications. Samples will only be
given at scheduled appointments and are only authorized by the doctor.
__________
Initial
_________
Date
Missed Appointment Dismissals:
Patients must notify this office 24 hours prior to your appointment if you need to reschedule or cancel. If you fail to
notify the office within this time frame 3 times within a 1 year period, we have the right to dismiss you from the
practice for noncompliance. If you do not show up for 3 appointments within a 1 year period, we have the right to
dismiss you from the practice for noncompliance.
__________
Initial
_________
Date
Revised 9‐2‐15
History & Physical
Name: _____________________ Date of Birth: ___ /___ /___
Medical History:
Harris Medical Group
Today's Date: ___ /___ /___
Have you ever been diagnosed with any of the following?
Allergies / Hay fever
Dizziness / Fainting
Menstrual dysfunction
Anemia
Epilepsy
Osteoporosis
Anxiety
Fatigue
Painful Breathing
Arthritis
GI Disorder
Parkinson's Disease
Arrhythmia
Glaucoma
Pneumonia
Asthma
Gout
Poor Circulation
Bleeding Problems
Headache
Psychological disorders
Blood Clots
Heart Attack / MI
Reflux
Cancer (please specify)
Heart murmur
Rheumatic fever
Heart palpitations
Scarlet fever
Chest pain / Angina
Hepatitis-type Infection
Seizures
Crohn's Disease
Hiatal Hernia
Sexual dysfunction
Congenital heart disease
High Blood Pressure
Shortness of breath
Congestive heart failure
HIV / AIDS
STD
COPD
Hyperlipidemia
Stroke / TIAs
Coronary Artery Disease
Incontinence
Thyroid Disease
Cough/Cold (recent)
Kidney Stones
Ulcer
Depression
Liver disease
Ulcerative Colitis
Diabetes
Meningitis
Urinary issues
___________________
Surgical/Hospitalization History: Please list all, including minor procedures.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Diabetes
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Thyroid Disease
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Please indicate any family history of the following.
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Family History:
History & Physical
Harris Medical Group
Name: _____________________ Date of Birth: ___ /___ /___
Today's Date: ___ /___ /___
Social History:
Do you smoke?
Yes
Do you consume alcohol
No
If Yes: How many packs daily? __________
How long have you smoked?
Yes
Interested in quitting?
Recently quit smoking?
_______
No
Do you exercise?
____________________
Are you sexually active?
Sexual Preference:
Men
Yes
Women
Married
Single
Do you have children?
Are you employed?
Health Maintenance
Yes
Yes
No
No preference (bi-sexual)
What form(s) of birth control do you use?
Marital Status
No
Do you have any difficulties sleeping?
No
Yes
No
Yes
Yes
_______________________
How often?
No
Do you have a history of domestic violence?
No
Yes
Yes
If Yes: How much? ____________________
No
Do you use drugs?
If Yes: What?
Do you consume caffeine?
If Yes: How much? ____________________
Do you use any other form of tobacco?
Yes
No
If Yes: How much? ____________________
No
Yes
Yes
__________________________________________
Widowed
Divorced
No
No
If Yes: Where?
____________________________________
Please list the most recent date of each of the following.
Male:
Female:
Flu Shot: ____________________
Flu Shot: ____________________
Pneumonia Vaccine: ____________________
Pneumonia Vaccine: ____________________
Colonoscopy: ____________________
Colonoscopy: ____________________
PSA Screening: ____________________
PAP Smear: ____________________
Mammogram: ____________________
First day of Last Menstrual Period: ____________________
Obstetrical History:
Women only, please list how many of each of the following you have had.
Pregnancies:
_________
Preterm deliveries:
_________
Miscarriages:
_________
Vaginal deliveries:
_________
Abortions:
_________
Cesarean Sections:
_________
_________
How many children do you have?
Full term deliveries:
_________________
History & Physical
Name: _____________________ Date of Birth: ___ /___ /___
Harris Medical Group
Today's Date: ___ /___ /___
Today's Visit:
Age: _____
Height: _____
Weight: _____
Family Physician: _______________________
Chief Complaint: _________________________________________________________________
Where on your body are you experiencing this?
________________________________________
What symptoms are you experiencing? ________________________________________________
How long have you had these symptoms? _____________________________________________
Have you ever had these symptoms before?
Are you here today due to an injury?
___________________________________________
Yes
No
What is the estimated date of your injury/onset of pain? ___ / ___ / ___
How did you sustain your injury?
______________________________________________________________________________
On a scale of 1 - 10, what is your level of pain? (circle)
1
2
(No Pain)
3
4
6
5
7
8
9
10
(Severe Pain)
Allergies:
Do you have any drug allergies?
Yes
No
If yes, please list drug and reaction.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Do you have any other allergies
Yes
No
If yes, please list allergy and reaction.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Medications
Please list all medications with dosage and strength, including over-the-counter meds/vitamins.
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
______________________________________
Please briefly describe any other issues you would like to discuss today.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________