MI:

Social Security Number: Date of Birth: Age: Gender: Race: Martial Status Ethnicity: (Circle one):

Latino Non-Latino Other

City: State: Zip Code:

City: State: Zip Code:

Work Number:

Cell Number:

Date of Birth:

Date of Birth:

Signature: _________________________________________________ Date: _______________________________

6. Communication: I authorize the use of my email to contact me.

8. Multimedia Use: Yes, I consent to allowing AC to use any photographs or videos for multimedia use knowing all identifiers

No, I do NOT consent to allowing AC to use any photographs or videos for multimedia use despite the

physicians and/or medical facilities.

3. Assignment of Benefits: I request that payment of authorized insurance benefits be made on my behalf to AC.

4. Financial Responsibility: I understand that AC will file my insurance as a courtesy to me and that I remain responsible for

payment of co-pays, coinsurance, deductibles, non-covered services and any other charges not paid by insurance with 45 days.

5. Patient Rights: I have received a letter of patient rights.

of my identity will be removed prior to publication.

Authorizations, Medical Records Release, Assignment of Benefits1. Treatment Authorization: I authorize you to give me reasonable and proper medial care by today's standards.

2. Release of Information: I authorize release of my records to Ashford Clinic (AC) including HIV, psychiatric, drug/abuse records,

venereal disease and any other statutory protected disease, as necessary for continued medical care, to obtain insurance

reimbursement or to comply with utilization review. I authorize this office to obtain previous medical records from other

Employed by: Occupation: Can we contact you at work?

YES NO

Date: Last Name:

Language:

First Name:

Address (Street, Route, Apt. No, ect.)

Home Phone: Cell Number: Email Address:

EMPLOYER INFORMATION

Work Number: Employer's Address:

SPOUSE/GUARDIAN (If patient is a child, please give parent information)Name: Relationship to patient: Responsible for bill:

YES NO

Phone Number:

PHARMACY INFORMATION

Home Phone: Cell Number: Can we contact you at work?

YES NO

EMERGENCY CONTACTName: Relationship: Home Phone: Work Number:

removal of all of my identifiers.

Secondary Insurance Name: Subscriber Name: Relationship to patient:

Patient Registration Form Please Fill out Completely

Preferred Pharmacy: Phone Number: Pharmacy Location:

INSURANCE INFORMATION - Please provide your insurance card(s) at the time of visitPrimary Insurance Name: Subscriber Name: Relationship to patient:

PHYSICIAN INFORMATIONPrimary Care Physician Name: Phone Number:

Referring Physician Name:

Text

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What is your primary problem bringing you here today? (please describe your symptoms) __________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

How long have you had these issues? ___________________________________________________________________________________

Do you use tobacco products? ☐ Never ☐ Quit (quit date:________________) ☐ Yes (if yes, please describe the type, how much, and how often) __________________________________________________________________________________________________________________

How often do you drink alcohol? ☐ Never ☐ Daily ☐ Weekly ☐ Occasionally

Personal use of recreational drugs? ☐ No ☐ Yes

Do you have any allergies? ☐ No ☐ Yes (if yes, please list any allergies to medications, IV contrast or pollens) __________________________________________________________________________________________________________________

Have you ever had a CT scan? If so, when and where? ____________________________________________________________________

__________________________________________________________________________________________________________________

Please list any medical problems: ______________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Please list previous surgeries/procedures:

Procedure/Surgery Date Procedure/Surgery Date

1.______________________________________________________ 2._________________________________________________________

3.______________________________________________________ 4._________________________________________________________

5.______________________________________________________ 6._________________________________________________________

List medications you are currently taking: (including prescriptions, over the counter, and herbal)

Medication Dose Frequency Medication Dose Frequency

1.______________________________________________________ 2._________________________________________________________

3.______________________________________________________ 4._________________________________________________________

5.______________________________________________________ 6._________________________________________________________

7.______________________________________________________ 8._________________________________________________________

9.______________________________________________________ 10.________________________________________________________

Do you have problems with any of the following? Please circle yes or no.

General: Weight loss……………..……….. yes no Weight gain………….………….. yes no Fatigue.……………….…………. yes no Night sweats…………………..… yes no Fevers/chills………………….…. yes no Easy bleeding/bruising…….…… yes no Heat/cold intolerance……..……. yes no Heavy menses……………..…… yes no Excessive sweating………..…… yes no

Face: Pain……………………..……….. yes no Numbness………………..……… yes no Twitching…………………..…….. yes no Weakness…………………….…. yes no Lop-sided…………………….….. yes no Previous Bell’s palsy…………… yes no

Eyes: Recent changes in vision…….… yes no Blurry/double vision…………..… yes no Wear glasses/contacts…….…… yes no Floaters…………………….……. yes no Glaucoma………………….……. yes no Cataracts…………………….….. yes no Watery or itchy eyes………….… yes no Dry eyes…………………….…… yes no Previous eye surgery……….….. yes no Blindness…………………….….. yes no

Ears: Ear pain……………………..…… yes no Ear drainage………………..…… yes no Ear pressure………………..…… yes no Ear fullness………………..…….. yes no Ringing/roaring noises…….…… yes no Pulsing noises……………..……. yes no Dizzy…………………………..…. yes no Vertigo………………………..….. yes no Previous ear surgery………..….. yes no Ear infections………………….… yes no Use Q-tips…………………..…… yes no Too much wax…………………… yes no Ear tubes………………….…….. yes no

Hearing: Hearing Loss………………… yes no Recent changes in hearing… yes no Hearing going up and down.. yes no Use of hearing aids…………. yes no Deafness…………………….. yes no

Nose: Obstruction…………………….… yes no Post-nasal drainage………….… yes no Nasal congestion/stuffiness…… yes no Purulent/foul nasal drainage..… yes no Itchy, watery nose…………….… yes no Frequent sneezing……………… yes no Nasal allergies………………..… yes no Nosebleeds……………………… yes no Difficulty breathing through nose…………….……… yes no Nose surgery………….………… yes no

Sinuses: Sinus headaches………………………..….. yes no Sinus pressure: cheeks…………………….. yes no Sinus pressure: forehead…………………… yes no Sinus pressure: eyes……………..………… yes no Colds last longer than average..…………… yes no Frequent sinus infections…………………… yes no Chronic sinus infections………………….…. yes no Sinus surgery………………………………… yes no Tooth pain……………………………….……. yes no Altered smell/taste…………………….…….. yes no

Throat: Sore throat………………………..……….… yes no Dry mouth/throat……………………….……. yes no Difficulty swallowing………………………… yes no Painful swallowing…………………….…….. yes no Frequent throat/tonsil infections…………… yes no Something stuck in throat……………..…… yes no Hoarseness………………………………….. yes no Voice wears out quickly…………………….. yes no Weak voice………………………….……….. yes no Voice tremor or stutter………………….…… yes no Frequent throat clearing……………………. yes no Increased phlegm.……………………..…… yes no Food sticking or going down wrong……….. yes no Lesion in mouth/throat………………….…… yes no Previous tonsil/adenoid surgery………..….. yes no

Neck: Pain………………………………..………….. yes no Mass/lump…………..………………….……. yes no Goiter…………………………………….…… yes no Previous spine surgery……………….…….. yes no Decreased neck mobility……….….…….…. yes no Thyroid problem……………………….…….. yes no Thyroid nodule..……………………………… yes no

Skin: Skin cancer…………………………….…….. yes no Skin lesion…………………….……………… yes no Dry skin………………………………………. yes no Rashes……………………………………….. yes no Changes to skin/hair/nails……………….…. yes no Eczema…………………………………..…… yes no

Immunologic: Abnormal/large lymph nodes……..….……. yes no Rheumatoid arthritis……….………..……… yes no Lupus…………………….…….……..……… yes no Sjogren’s……………………..………..…….. yes no Wegener’s.…………………..………..…….. yes no Sarcoidosis…………………………….…….. yes no Psoriasis………………………..…………….. yes no Previous transplant.…………………..…….. yes no HIV/AIDS……………………………..….….. yes no Hepatitis B/C……………………….………… yes no

Gastrointestinal: Stomach pain/cramping…………….…….… yes no Diarrhea………………………….…………… yes no Constipation…………………………………. yes no Nausea………………………….……………. yes no Vomiting……………………………….……… yes no Appetite changes………………….………… yes no Blood in stool………………………………… yes no Heartburn…………….…………………….… yes no

Neurologic: Stroke……………………………………….… yes no Headaches…………………….………….….. yes no Migraines……………………….…………….. yes no Numbness/tingling……………….………….. yes no Weakness…………………………….………. yes no Walking problems………………………….… yes no Frequent falls………………………………… yes no Difficulty thinking/memory loss…………….. yes no Passing out……………………….………….. yes no Dizzy or giddy feeling……………………….. yes no Light-headed..…………………………..…… yes no

Heart: Heart attack………………………………….. yes no Heart failure………………………………..… yes no Chest pain………………………………….… yes no Abnormal rhythm…………………………….. yes no Palpitations/funny heart beat………………. yes no Blood thinner use……………………………. yes no Pacemaker…………………………………… yes no Previous heart surgery/CABG………..…… yes no Shortness of breath lying flat……….…..…. yes no Pain in calves when walking……………….. yes no Fast or slow heart rate……………..………. yes no High blood pressure…………………..……. yes no Swelling in legs……………………………….yes no

Lungs: Breathing problems…………………………. yes no Asthma………………………………..…..…. yes no COPD/emphysema………………………..… yes no Smoking………………………………….…… yes no Dry cough……………………………………. yes no Cough with phlegm/sputum………………… yes no Cough up blood……………………………… yes no Wheezing…………………………………..… yes no Shortness of breath at rest……………….… yes no Shortness of breath walking………..……… yes no Noisy breathing……………………………… yes no Use of oxygen.………………………………. yes no

Sleep: Difficulty falling/staying asleep…….………. yes no Problems sleeping…….……………….……. yes no Sleep apnea…………………………….…… yes no Use of CPAP/BiPap……………………….… yes no Snoring…………………………………….…. yes no Wake up frequently……………………….…. yes no Stop breathing at night…………….……….. yes no Choking/gagging during sleep…..………… yes no Sleepy during day/not well rested….……… yes no

Other: Osteoarthritis………………………………… yes no Diabetes……………………………………… yes no Depression………………………….…….….. yes no Anxiety………………………………….…….. yes no Bipolar disorder………………………..…….. yes no Fibromyalgia………..………………….…….. yes no ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________