Patient Forms - Doctor Castellano

Patient Information

Name

First Last

What is your reason for visit?*

SS/HIC/Patient ID#*

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex*

Male
Female

Age*

Birthdate*

Martial Status*

Spouse's Name

First Last

Spouse's Birthdate

Spouse's SSN

Occupation*

Patient Employer/School*

Employer/School Phone

Employer/School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Spouse's Employer

Whom may we thank for referring you?*

Insurance

Who is responsible for this account?*

Relationship to Patient

Insurance Company

Group #

Is patient covered by additional insurance?*

Yes
No

Subscriber's Name

First Last

Subscriber's Birthdate

Subscriber's SSN

Relationship to Patient

Insurance Company

Group #

Phone Numbers

Cell Phone*

Home Phone

In Case Of Emergency Contact

First Last

Phone

Work Phone

Emergency Contact Relationship To Patient

Family History

Father*

Alive
Deceased

Mother*

Alive
Deceased

Spouse

Alive
Deceased

Father's Present Health*

Father's Cause of Death*

Mother's Present Health*

Mother's Cause of Death*

Spouses' Present Health

Spouses' Cause of Death

Patient Has Siblings?

Yes
No

Patient Has Children?

Yes
No

Brother(s)*

Alive
Deceased
No Brother(s)

Sister(s)*

Alive
Deceased
No Sister(s)

Brother(s) Current Health or Cause of Death

Sister(s) Current Health or Cause of Death

Children*

Alive
Deceased
No Children

Children's Ages/Health/Cause of Death

Health History

Check symptoms you currently have or have had in the past year.

Date of Last Physical Examination*

GENERAL

MUSCLES/JOINT/BONE

Pain, weakness, numbness in:

Genito-Urinary

Blood in urine
Frequent urination
Lack of bladder control
Painful urination

GASTROINTESTINAL

CARDIOVASCULAR

EYE, EAR, NOSE, THROAT

SKIN

MEN ONLY

WOMEN ONLY

Date of Last Menstrual Period

Date of last Pap Smear

Have you had a mammogram?

Are you pregnant?

Number of Children

Check conditions you have or have had in the past.

Describe Serious Illnesses or Operations

Medications/Allergies

List medications you are currently taking

List allergies to medications or substances

Pharmacy Name*

Phone*

Health Habits

Check if your work exposes you to:

Stress
Heavy Lifting
Hazardous Substances
Other

Check which substances you use:

Caffeine
Street Drugs
Tobacco
Other

How often do you use the selected substance(s)?

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