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Patient Intake Form
+
Services
+
Our Team
+
Certified Providers
+
Administrative Team
+
Specialists
+
Call Us
702-779-3902
Schedule An Appointment
New Form
Relianthealth
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COVID QUESTIONNAIRE
Patient Name:
Current Body Temperature:
Date:
Within the past 14 days, have you been in close physical contract with anyone who is known to have laboratory-confirmed COVID-19?
Yes
NO
Within in the past 14 days, have you or members of your household traveled outside of Nevada?
Yes
No
Within the past 24 hours, have you or anyone in your household recorded a fever of 100.4 degrees Fahrenheit or higher.
Yes
No
Does anyone in your household currently have COVID-19?
Yes
No
New Patient Registration Form
Full Name:
Social Security Number:
i
Social Security Number Must in Format ______-_____-_______
Date of Birth:
Address:
Your Gender
Male
Female
Age:
Email:
Cell Phone:
Work Phone
Employer:
Insurance Information
Primary insurance:
Policy Number:
Group Number:
Insurance Phone Number:
Guarantor Insurance Information:
Self
Spouse
Parent
Guarantor Name(if other than patient):
DOB:
SSN:
Secondary insurance:
Policy Number:
Group Number:
Insurance Phone Number:
Guarantor Insurance Information:
Self
Spouse
Parent
Guarantor Name(if other than patient):
DOB:
SSN:
Is your visit due to a job-related injury or automobile accident?
Yes
No
If yes, please notify our receptionist.
Emergency Contact
Person to notify in case of Emergency:
Phone:
Relationship to patient:
Who do you give the right to release your medical records to?
Pharmacy Information
Preferred Pharmacy:
Major Cross Streets:
Phone Number:
I authorized the release of any medical information necessary to process this to my insurance company and request payment of benefits to ReliantHealth. I acknowledge that I am financially responsible for payment whether covered by insurance.
Signature:
Date:
New Patient History
I. Identifying Information:
Name:
DOB:
List any other physicians or health care providers you see:
II. Medical History
List any medical problems that you have.
Check if you have or have you ever had:
Alcohol abuse
Asthma
Asthma
Anemia
Bleeding disorder
Blood cloths
Chronic lung condition
Chronic lung condition
Depression/anxiety
Diabetes
Heart disease
High blood pressure
High cholesterol
Hepatitis/Jaundice
Cancer(Type)
Irritable bowel syndrome
Kidney stone
Hypothyroidim
Seizure disorder
Stroke
Tuberculosis
Stomach ulcers
Stomach ulcers
Stomach ulcers
Transfusion reaction
Eating disorder
Lupus/autoimmune
III. Allergies and Medications:
Are you allergic to any of the following? If yes, what is the effect?
Aspirin
Local Anesthetics
Acrylic
Metal
Penicillin
Latex
Sulfa Drug
Codeine
Other
List all medications that you take with the dose and timing (including all non-prescription medications that you take regularly including vitamins, herbs and anti-inflammatory medications.):
Drug
Dose
Frequency
Reason for medication
IV. Surgical history: List all surgeries you have had
Description:
Date:
