New Patient Registration Form Name *FirstLastDate of Birth *Email *Phone Number *Mailing Address *Insurance *Subscriber IDGender *FemaleMaleTransgeder, Male to FemaleTransgender, Female to MaleOtherMarital Status *SingleMarriedSeparatedDivorcedWidowedOtherRace/ Ethnicity *African American or BlackAmerican Indian or Alaska NativeCaucasian or WhiteHispanicPacific Islander or Native HawaiianOtherPrimary LanguageEnglishSpanishOtherOther, List BelowOccupation/ Student Status *Full-time EmployedPart-time EmployedFull-time StudentPart-time StudentRetiredUnemployedFull-time Mother/ FatherOtherNumber of People in the Household, including yourself *12345678910+Emergency Contact's Name *Emergency Contact's Relationship to Patient *Emergency Contact's Telephone Number *Preferred Pharmacy *Preferred Pharmacy's Address and Phone Number *What is the Primary Reason for your Appointment? *Establish a new PCPAcute IllnessMedication RefillManage Chronic ConditionsAnnual Wellness ExamVaccinationTravel HealthWeight LossDiscuss a ProblemOtherOther, List BelowWhat else would you like to ask or add to your appointment request?Are You disabled?NoYesDo you wear contacts or glasses?NoYesDo you have a hearing impairment?NoYesAre you able to pay for your medications?NoYesDo you currently use tobacco in any form?NoYesIf yes, what type, how many packs per day and # of yearsAre you a former smoker?NoYesIf yes, when did you stop?Have you had alcohol in the past 12 months?NoYesIf yes, how often? (# of days per week)01234567Do you use recreational/ street drugs?NoYesIf yes, what drugs do you use?Have you been sexually active in the last 12 months?NoYesIf yes, what type of partners?None1 Male1 Female2+ Males2+ FemalesMale and FemaleDo you have any history of Sexually Transmitted Infections (STI)?NoYesDo you have an Advanced Directive or Living Will?NoYesIf No, would like information on this today?NoYesIn the last two week, have you felt sad, depressed or hopeless? *NoYesIn the last two weeks, have you have little interest or pleasure in the things you used to like to do? *NoYesHow did you hear about us?WebsiteSubmit