Home
Clinic Hours
Locations
Birmingham
Jasper
New Patient Paperwork
Submit Online
Download PDF
Blog
FAQ
About Us
About Us
In the News
Contact Us
Request Appointment / More Information
Phone: 205-731-9090
Fax: 205-731-0760
Home
Clinic Hours
Locations
Birmingham
Jasper
New Patient Paperwork
Submit Online
Download PDF
Blog
FAQ
About Us
About Us
In the News
Contact Us
Request Appointment / More Information
Phone: 205-731-9090
Fax: 205-731-0760
NEW PATIENT PAPERWORK
New Patient Paperwork
1
Personal Information
2
Health Insurance
3
Email/Text Reminders
4
Medical & Social History
5
Substance Use History
Personal Information
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
*
Social Security Number
*
Marital Status
*
Single
Married
Divorced
Widowed
Home Phone
Cell Phone
Work Phone
Emergency Medical Contact
Emergency Medical Contact
*
Relationship
*
Emergency Medical Contact Phone
*
Primary Care Physician
Primary Care Physician Phone
Do you have Health Insurance?
*
Yes
No
Primary Insurance
Primary Insurance
Policy #
Group #
Subscriber Name
Subscriber Date of Birth
MM slash DD slash YYYY
SSN
Secondary Insurance
Secondary Insurance
Policy #
Group #
Subscriber Name
Subscriber Date of Birth
MM slash DD slash YYYY
SSN
Are you interested in receiving EMAIL reminders regarding your appointments?
Yes
No
Email
Are you interested in receiving TEXT MESSAGE reminders regarding your appointments?
Yes
No
Cell Phone
Drug Allergies
Other Allergies
Are you currently taking any prescribed medications? (Including vitamins and oral contraceptives)?
Yes
No
Medication/Dose
Please list ALL medical problems/illnesses for which you are currently being treated
List any surgeries/hospitalizations you have had, the year and any complications
When was your last physical?
MM slash DD slash YYYY
Are you Pregnant?
Yes
No
Last Menstrual Cycle?
MM slash DD slash YYYY
If you are currently or you have experienced problems with any of the following conditions listed below, PLEASE CHECK “Yes” or “No”. PLEASE CHECK “Family” if you have a family history of the condition.
Pneumonia
*
Yes
No
Family
Ulcer
*
Yes
No
Family
High Blood Pressure
*
Yes
No
Family
Cancer
*
Yes
No
Family
Blood Clot
*
Yes
No
Family
Cysts
*
Yes
No
Family
HIV/AIDS
*
Yes
No
Family
Diabetes
*
Yes
No
Family
Heart Disease
*
Yes
No
Family
Thyroid Disorder
*
Yes
No
Family
Phlebitis
*
Yes
No
Family
Osteoporosis
*
Yes
No
Family
Rheumatic Fever
*
Yes
No
Family
Anxiety
*
Yes
No
Family
Kidney Disease
*
Yes
No
Family
Epilepsy/Seizures
*
Yes
No
Family
Anemia
*
Yes
No
Family
Liver Disease
*
Yes
No
Family
Tuberculosis
*
Yes
No
Family
Stroke
*
Yes
No
Family
Emphysema
*
Yes
No
Family
Hepatitis
*
Yes
No
Family
Arthritis
*
Yes
No
Family
Abnormal Breathing
*
Yes
No
Family
Vascular Disease
*
Yes
No
Family
Asthma
*
Yes
No
Family
Migraine/Headache
*
Yes
No
Family
Alcoholism
*
Yes
No
Family
Addiction
*
Yes
No
Family
Mental Health
*
Yes
No
Family
Tobacco Products
None
Cigarettes
Smokeless
Pipe
How many per day?
How many years?
How long have you been abusing substances?
Have you been treated for substance abuse?
Yes
No
Please describe when, where and for how long?
Substance Abuse History
Alchohol
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Caffeine (pills/drinks)
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Cocaine
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Crystal Meth
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Heroin
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Inhalants
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
LSD/Hallucinogens
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Marijuana
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Methadone
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Pain Killers
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
PCP
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Stimulants (pills)
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Tranquilizers
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Ecstasy
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Other
*
No
Yes/Past
Yes/Current
Route (i.e. oral, IV)
How much
How often
Date of Last Use
MM slash DD slash YYYY
Time of Last Use
:
Hours
Minutes
AM
PM
AM/PM
Qty Last Used
Signature
Signature
*
Digital Signature
Please sign digitally by checking the box. Signature below will be required in office.
_____________________________________________________________________
Patient/Guardian Signature
____________________
Date
