New Patient Forms
PATIENT HISTORY
Dr. Ron Tripp
PERSONAL INFORMATION
Name___________________________________________________________Date__________________
Address____________________________________________City____________State_____Zip________
E-mail ________________________________________________________________________________
Phone# _________________Social Security# _____ _____________Driver License# _________________
Age ____ Birth date _____________ Sex _______ Marriage Status: M S W D No. children___________
Emergency contact _____________________________Phone# ______________________________
EMPLOYMENT
Occupation____________________________Employer_________________Yrs. Employed____________
Address _____________________________City __________State _____Work Phone________________
MAJOR COMPLAINT
Major complaint ________________________________________________________________________
Secondary complaints____________________________________________________________________
Do you recall similar symptoms in the past? __________________________________________
What activities aggravate your condition?___________________________________________
Is this condition getting progressively worse? Yes( ) No( ) Constant( ) Comes and goes( )
Is this condition interfering with your: Work( ) Sleep( ) Daily routine( ) Other_______________________
How long has it been since you really felt good?_______________________________________________
PREVIOUS TREATMENT
List surgical operations and year: ____________________________________________
________________________________________________________________________
List current medications/dosage: _____________________________________________
________________________________________________________________________
List other Doctors seen for this condition:______________________________________
________________________________________________________________________
INSURANCE INFORMATION:
Would you like us to file your insurance: Yes ( ) No ( )
Would you like to use your Master Card/Visa: Yes ( ) No ( )
Please provide a copy of your card on your first visit.
ACCIDENT INFORMATION:
Is this condition due to an accident? No ( ) Yes ( ) Auto ( ) Job ( ) Other ( )
How did you hear about our clinic? _________________________________________________
I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand 6that if I suspend or terminate my care an treatment, any fees for professional services rendered me will be immediately due and payable.
Patient’s signature: _____________________________________Date:______________________________________