Topanga Medical — Patient Intake

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Patient Registration Form Patient Identification

Sex

MaleFemale

Last Name*

First Name*

Middle Name

Street*

City*

State*

Zip*

Home Phone

Cell Phone

E-Mail

Social Security #

Driver's License #

DOB*

Age

If child, Parent's Name

Patient Occupation

Employer

Emergency Contact (Name and Phone # of Relative or Friend not residing with you)

Emergency Contact Phone

Referring Physician

Referring Physician Phone

Primary Care Physician (PCP)

PCP Phone

Pharmacy

Phone Number

Do you have an Advanced Directive on file

YesNo

Where

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Accident / Work Related Injury

Is this a accident or work related injury

YesNo

Date of Injury

Claim #

Adjuster's/Attorney Name

Adjuster's/Attorney Phone

Workers Comp Carrier

Worker's Comp Phone

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Insurance Information - Must Be Filled Out in Full Along With a Copy of Your Insurance Card

Please present your insurance card to the receptionist at the beginning of your office visit.

Primary Insurance Company

Subscriber ID

Group ID

Subscriber name

Date of Birth

Relationship to the patient

How did you hear about our office

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Medical Information

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Personal Medical History - Check All That Apply to You

Personal Medical History

Condition

Yes/No

Please list any other conditions

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Family Medical History Check All That Apply to Your Family

Family Medical History

Condition

Member & Age

Yes/No

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Intake Questions

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Previous Conservative Treatment of the Spine

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Previous Surgical Treatment of the Spine

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Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks how often have your been bothered by any of the following problems

Appointment Date✓ From EHR

Little interest or pleaser in doing things

Not at allSeveral DaysMore than half the daysNearly everyday

Feeling down, depressed, or hopeless

Not at allSeveral daysMore than half the daysNearly everyday

Trouble falling or staying asleep, or sleeping too much