Pinnacle Medical Group Patient Registration Form PATIENT INFORMATION (Please Print)

Dr. Miss Mr. Mrs. Ms. SirPatient’s Name (Last)_________________________________ (First)____________________________ (MI) ______________ Previous Name (Last) ______________________________________ (First) _________________________________________Address___________________________________________City_______________________ State_____ Zip ______________Home Phone_______________________ Cell_______________________ Work________________________ Ext. ________Primary Care Provider (PCP)____________________________ Referring Provider ____________________________________Email Address ___________________________________________________________________________________________Date of Birth _______/_______/_________ Female Male Transgender Race American Indian or Alaska Native Asian Native Hawaiian or other Pacific Island Black or African American White Decline

Ethnicity Hispanic or Latino Not Hispanic or Latino DeclinedLanguage English Spanish Japanese Chinese French German Russian Other __________Marital Status Married Single Divorced Widowed Legally Separated PartnerSocial Security No. ________-_______-__________ Employer Name _____________________________________________Employment Status 1 - Full Time 2 - Part Time 3 - Not Employed 4 - Self-Employed 5 - Retired 6 - Active Military

Student Status F - Full Time Student P - Part Time Student N - Not a Student Do you have a living will? Yes No

Emergency Contact Name________________________________________ Phone Number _____________________________Emergency Contact Relationship to Patient __________________________________________________________ GuardianHome Phone_______________________ Cell_______________________ Work________________________ Ext. ________

RESPONSIBLE PARTY INFORMATION (Information used for patient balance statements)

Responsible Party Guarantor SelfResponsible Party Name (Last)______________________________ (First)____________________________ (MI) _________ Also Known As Name (Last) ______________________________________ (First) ____________________________________Date of Birth _____/_____/________ Female Male Social Security No. _______-______-_______Home Phone_______________________ Cell_______________________ Work________________________ Ext. ________Address___________________________________________City_______________________ State_____ Zip ______________Employer________________________________________________ Employer Phone _________________________________

PRIMARY INSURANCE INFORMATION (Provide your insurance card to the front desk at check-in)

Insurance Company _____________________________________ Insurance Company Phone __________________________Name of Insured________________________________________ Patient Relationship to Insured ________________________Subscriber ID (Policy Number)__________________________ Group ID____________________ Copay Amount____________Effective Date_____/_____/________ Termination Date_____/_____/________ Date of Birth _____/_____/________

SECONDARY INSURANCE INFORMATION (Provide your insurance card to the front desk at check-in)

Insurance Company _____________________________________ Insurance Company Phone __________________________Name of Insured________________________________________ Patient Relationship to Insured ________________________Subscriber ID (Policy Number)__________________________ Group ID____________________ Copay Amount____________Effective Date_____/_____/________ Termination Date_____/_____/________ Date of Birth _____/_____/________

I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.

Patient (or Responsible Party) Signature_____________________________________________ Date_____/_____/________

PinnacleMedical Group 8/13

Pinnacle Medical Primary Care

MEDICAL HISTORY FORM

Date: _________________________ Date of Last Physical Exam: _____________________

Patient Name: _____________________________________________________ Date of Birth: ___________________

Patient Current Concerns: __________________________________________________________________________

Preferred Pharmacy: ______________________________________ Phone: _____________________________

MEDICATIONS ALLERGIESLIST ALL MEDICATIONS YOU ARE CURRENTYLY TAKING ___________________________________________INCLUDE VITAMINS, HERBS, SUPPLEMENTS, ETC. ___________________________________________

SOCIAL HISTORYDo you smoke? YES NO How much per day? ____

If you quit smoking, when? ______Do you use a vape? YES NOIf yes, how often do you vape? _______How many years have you smoked? ______

PLEASE LIST ANY OF THE FOLLOWING THAT APPLY TO YOUR HEALTH (w/ dates if applicable):CHRONIC CONDTIONS ACCIDENTS/INJURIES HOSPITALIZATIONS_________________________ ____ ____________________________ ____________________________________________________________ ____________________________ ______________________________SURGERIES DIAGNOSTIC TESTS RECENT LABS

______________________________ ______________________________ ______________________________

______________________________ ______________________________ ______________________________

LAST COLONOSCOPY FLU VACCINE PNEUMONIA VACCINE

______________________________ _____________________________ ______________________________

(Female patients)

LAST MAMMOGRAM LAST PAP SMEAR DO YOU TAKE ORAL CONTRACEPTIVES? YES NO

______________________________ ________________________

DIABETIC PATIENTS When was your last eye exam? _________________ Where? _____________________________How often do you check your blood sugar? ___________________ What was your last A1C result? ________________

65 AND OVER Have you fallen in the past year? YES NO If yes, do you know what caused the fall? _______________

CERTIFICATIONTo the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

_______________________________________________________________ _______________Signature of Patient, Parent, Guardian or Personal Representative Date

_______________________________________________________________ ________________Please print name of Patient, Parent, Guardian or Personal Representative Date

Pinnacle Medical Primary Care

Patient Name: _____________________________________________________ Date of Birth:_______________________________

PATIENT HEALTH QUESTIONNAIRE

We are asking questions pertaining to your current mood to assess your physical as well as psychological well-being. We understand the sensitivity of these questions and assure you that your answers will remain private.

Over the past two weeks, how often have you been bothered by any of these problems?

LITTLE INTEREST OR PLEASURE IN DOING THINGS? YES NO FEELING DOWN, DEPRESSED, OR HOPELESS? YES NO

If you answered YES to either of the above questions above please proceed with answering the following:

Over the last 2 weeks, how often have you been botheredby any of the following problems?(Use “✔” to indicate your answer)

Nearlyeveryday

Morethan halfthe days

SeveraldaysNot at all

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating ont things, such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless 0 1 2 3 that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3