MARYVILLE PHYSICIAN SERVICES, LLC
Anita Sandhu, M.D.
PATIENT REGISTRATION
Patient Last Name ________________________ First Name _____________________ Middle Initial ________
Address _________________________________ City__________________ State _______ Zip ___________
Home Phone ___________________ Work Phone __________________ Cell Phone ____________________
Email address ___________________________________ Fax ___________________________
SS# ____________________________ Date of Birth __________________
Marital Status ____________________
Employer Name __________________________________________ Phone _____________________________
Employer Address _______________________________ City ________________ State ______ Zip ________
Which is preferred phone number to call? ___Home, ___Work,
___Cell.
Is it okay to leave voice mail messages with private health information? ___Yes, ___No
How would you like to receive lab results or notice of other reports? ___Fax, ___Email,___Standard Mail
INSURANCE INFORMATION
Primary Insurance
Insurance Name __________________________ Policy # ______________________ Phone _________________
Name of Insured _________________________________________ Relationship ___________________________
SS# ________________________ Date of Birth _______________________
Employer Name __________________________________________ Phone _____________________________
Employer Address _______________________________ City ________________ State ______ Zip ________
Secondary Insurance
Insurance Name __________________________ Policy # ______________________ Phone _________________
Name of Insured ________________________________________ Relationship ___________________________
SS# ________________________ Date of Birth _______________________
Employer Name _________________________________________ Phone _____________________________
Employer Address ______________________________ City ________________ State ______ Zip ________
Referring Physician Name ____________________________ Phone _______________________________
PCP Name _________________________________________ Phone _______________________________
Emergency Contact __________________________________ Phone _______________________________
I hereby authorize the providers of Maryville Physician Services, LLC, AnitaSandhu, M.D. to treat the patient identified above. I acknowledge
that I am responsible to pay allcharges for all treatments administered by the physician to the patient. I understand that insurance may not pay
for all charges and I understand that Iam obligated to pay for all charges not paid by insurance. I also agree to pay reasonable attorney fees if
my account is turned over to an attorney orcollection agency.Assignment and Release: I hereby authorize my insurance benefits to be paid
directly to the physician and understand I am financially responsiblefor non-covered services. I also authorize the physician to release any
information required in the processing of this claim and all future claims.I acknowledge receipt of the Notice of Privacy Practices for Maryville
Physician Services, LLC, AnitaSandhu, M.D.
Signature of Patient / Authorized Person______________________________________________ Date ___________________
1
MARYVILLE PHYHSICIAN SERVICES, LLC
ANITA SANDHU, M.D.
Date__________________
Patient Name:______________________________________________
Do you have an advanced directive?_______________________________________________________
Medication History: Please list medications , dosage, frequency and problem, you are
CURRENTLY taking: Continue on back if necessary: BRING MEDICATIONS WITH YOU IF
YOU DO NOT COMPLETE THIS
Medication Name
Dosage
How Often
For what
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you take any non-prescription medications, health foods, vitamins?____________________________
____________________________________________________________________________________
____________________________________________________________________________________
Current
Pharmacy:___________________________________________________________________
Name
Phone Number
Location
ALLERGIES: List any medications or other substances that you are ALLERGIC to:
ALLERY
REACTION
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
2
Medical History: Please circle all past or present medical problems and/or symptoms:
ADD/ADHD
Alcoholism
Alzheimer's Disease
Anemia
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Back Pain
Blood Disorder
Cancer
Carotid Artery Disease
Cataracts
Congestive Heart Failure
COpD
Chest Pain
Depression
Diabetes
Drug or Substance Abuse
Glaucoma
Hearing Loss
Heart Disease
High Blood Pressure
Hyperlipidemia
Hypercalcemia
Hepatitis
Osteoporosis
Psychiatric Problems
Prostate Disease
Renal Disease
Stroke
Shortness of Breath
Seizure Disorder
Thyroid Disease
Visual Loss
Ulcers
Liver Disease
Lung Disease
Migraines
Obesity
Have you ever been in the hospital of had surgery? Yes or NO; If yes, please list type of surgery and
date of surgery, use the back if more space is needed.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3
FAMILY HISTORY: (IMMEDIATE) F=Father,M= Mother,B= Brothers, S=Sisters, G=Grandparents)
Alive:
Age
Medical Problems or Cause of Death
Father:___________________________________________________________________________
Mother:___________________________________________________________________________
Other:____________________________________________________________________________
Other:____________________________________________________________________________
Identify by F,(Father) M,(Mother) B,(Brother) S(Sister) or G ( Grand Parents Please
identify if Maternal or Paternal Grand Mother or Grand Father) if immediate family
member has or had any of the following:
ADD/ADHD ___
Alcoholism
___
Alzheimer's Disease ___
Anemia ___
Anxiety ___
Arthritis __
Asthma ___
Atrial Fibrillation ___
Back Pain
___
Blood Disorder ___
Cancer (What type) ___
Carotid Artery Disease ___
Cataracts
___
Congestive Heart Failure ___
COpD ___
Chest Pain
___
Depression ___
Diabetes
___
Drug or Substance Abuse ___
Glaucoma ___
Hearing Loss ___
Shortness of Breath __
Heart Disease ___
High Blood Pressure ___
Hyperlipidemia ___
Hypercalcemia ___
Hepatitis ___
Osteoporosis ___
Psychiatric Problems __
Prostate Disease ___
Renal Disease ___
Stroke ___
Seizure Disorder ___
Thyroid Disease ___
Visual Loss ____
Ulcers ____
Liver Disease ___
Lung Disease ___
Migraines ___
Obesity ___
SOCIAL HISTORY:
Do you use tobacco? yes or no. Cigarettes ______ Cigar ________ Chew __________
How many packs? ___________ How many years? ___________________
Have you tried to quit? ____________ How long have you quit?____________________
Do you drink alcohol? yes or no, If yes, how much _________________
and how often?________________
Are you watching your diet or following any strict dietary guidelines?______________________________
4
____________________________________________________________________________________
____________________________________________________________________________________
ADDITIONAL DEMOGRAPHIC INFORMATION
TO ALL PATIENTS:
The Centers for Medicare and Medicaid Services (CMS) and the Office of the National
Coordinator for Health Information Technology (ONC) recommend we ask patients to
provide the following (optional) information.
NAME__________________________________DATE OF BIRTH_________________
Race - Please check the appropriate answer:
Alaska Native ________
American Indian or Alaska Native __________
Asian _______
Black or African American _______
Greek _______
Hispanic______
Latino________
Native Hawaiian or Other Pacific Islander __________
White______
Other__________________________________________________________________________________
please specify
ETHNICITY
Hispanic or Latino __________
Not Hispanic or Latino ___________
PREFERRED SPOKEN LANGUAGE:
English: ________________
Other: ___________________________________________________________________
please specify
PREFERRED METHOD OF COMMUNICATION - PLEASE CHECK ONE
Phone _____
Mail _____
Secure Messaging ________
5