Birthdate ______________________________________ Male □ Female □ Social Security # _____
____ _____
Home phone
__________________________________
Cell Phone _____________________________________
Check the appropriate box: Minor □
Single □ Married □ Separated □ Divorced □ Widowed □
Patient's or parent's employer ________________________________ Work Phone
________________________
Person to contact in case of
emergency__________________________________ Phone ____________________
Insurance Information
Name
of Insured ____________________ Relationship to patient __________ Insurance I.D.# ______________
Name of Employer ____________________________________________
Work Phone _____________________
Insurance Company ____________________________________
Insurance Company Group # _______________
Insurance Co. Address _________________________________
City ________ State
______ Zip ___________
Insurance Company Phone No. (on insurance card) ___________________________________________________
Medical History
1. Past or current history and/or treatment of:
[Check all of the conditions that apply] or None □
Stroke □ Seizures
□ Migraines
□ Liver
Damage □ Thyroid
Problems □
Anemia □ Diabetes
□ Chronic
Pain □ Chronic
Fatigue □ Urinary
Tract Infections □
Asthma □ Hepatitis
□ Tuberculosis
□ Eating
Disorder □ Persistent
Flu-like Symptoms □
Cancer □ Hypertension
□ Allergies
□ Cardiac
Problems □ Communicable
Diseases □
2. Drug Allergies ______________________________________________________________________________
3. Current Medications
__________________________________________________________________________
4. Chemical Use History:
(Include substances used, age of onset, history and current use or denial of
chemical history) ______________________________________________________________________________________
_____________________________________________________________________________________________
5. Physical exam in the last year? Yes □ No □ Name of Primary Care Physician ___________________________
6. Pharmacy: Name ______________________________________
Phone Number ________________________
Authorization and Release
I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.X _________________________________________________________________________ _________________
Signature of patient (or parent if minor) Date
Please mail the completed form to:
Dr. J. Keyser, 382 Springfield Avenue Suite # 412, Summit, NJ 07901.