PATIENT INFORMATION

Patient Name:
Gender:
Marital Status:
Date Of Birth:
Social Security Number:
Address:
Number 1 (Home/Mobile):
Number 2 (Home/Mobile):
Email Address:

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person:
Name:
Relationship:
Telephone:

EMPLOYMENT INFORMATION

Employer:
Occupation:
Address:
Work Phone Number:
Do you have medical insurance?

IMPORTANT NOTICE

Under Florida Law, physicians are generally required to carry malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE.

This is permitted under Florida Law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida Law, Title XXXII, Chapter 458.320. The undersigned patient acknowledges that he or she has received a copy, read & understands this Medical Malpractice Insurance Notice. Furthermore, the undersigned acknowledges this notice was not signed under duress & that all of the patient’s questions relating heretofore have been answered to the patient’s satisfaction.

Date:
Patient's Signature:
Print Name:

HEALTH QUESTIONAIRE

All the questions contained in this questionnaire are strictly confidential & will become part of your medical record.

Surgery
Year Name of the procedure Hospital (optional)
List of your allergies to medicines or foods
List of your medications with prescription & over-the-counter medications, like vitamins & inhalers
Name of medication Dose Frequency of use
HABITS OF HEALTH & PERSONAL SAFETY
Exercise
Tobacco
Alcohol
Drugs Do you currently take recreational or street drugs?
Please enter all the problems that are there in your family
IMPORTANT/SIGNIFICANT HEALTH PROBLEMS
Mother
Father
Women’s Health Only