New Patient Paperwork – MedPlex Inc.

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Phone: 205-731-9090
Fax: 205-731-0760

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Home
Clinic Hours
Locations
- Birmingham
- Jasper
New Patient Paperwork
- Submit Online
- Download PDF
Blog
About Us
- About Us
- In the News
Contact Us
- Request Appointment / More Information
- Leave A Review
Phone: 205-731-9090
Fax: 205-731-0760

MedPlex-compass

NEW PATIENT PAPERWORK

New Patient Paperwork

1Personal Information

2Health Insurance

3Email/Text Reminders

4Medical & Social History

5Substance Use History

Personal Information
First Name*
Last Name*
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Address*
City*
State*
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

BIRMINGHAM OFFICE
3108 6th Avenue South
Birmingham, AL 35233
205-731-9090

JASPER OFFICE
1508 Highway 78 East
Jasper, AL 35501
205-295-5237

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