Nature Coast Primary Care
Patient Name: ______________________________________________________ DOB: _____________
Last First MI
Telephone Numbers: Home: ________________ Cell: _________________ Other:_______________
Mailing Address: _______________________________ City: __________________ State:_______ Zip:__________
SS#: ______ - ______- ________ Male Female Single Married Divorced Widowed
(Please Circle One) (Please Circle One)
Email Address:_________________________ How did you hear about our office?
Employer: _____________________________________ Phone Number:____________________________
Primary Insurance Carrier:_____________________________ Policy ID: ______________________________
Type of Plan: HMO PPO POS Other Insurance Carrier Phone #: ( ) _____________________
(Please Circle One)
Second Insurance Carrier: _______________________________ Policy ID: ____________________________
In case of an emergency, who would we contact? Name:______________________________________
Phone Number:____________________________ Relationship to patient:_______________________
CONSENT FOR E-PRESCRIBING & MEDICATION HISTORY: I understand that as a part of my electronic health record, Nature Coast Primary
Care will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider.
Additionally, Nature Coast Primary Care will obtain the history of all my past prescriptions dating back two years from the pharmacy benefit manager and I understand that those prescriptions will become a part of my electronic health record. By signing below, I hereby give consent to the above actions.
Patient/Guardian Signature: _____________________________________________________ Date: _____________
CONSENT FOR ELECTRONIC MEDICAL RECORD ACCESS: This confidential information may also include some or all of the following: diagnostic or treatment information relating to mental health or psychiatric condition; information relating to referrals for, or the diagnosis or treatment of, drug or alcohol abuse; genetic testing information or results; information relating to being a victim of, or counseling about, domestic abuse, neglect, or violence; and/or HIV/AIDS test results or treatment.
Patient/Guardian Signature: _____________________________________________________ Date:_____________
CONSENT TO TREAT: I authorize Nature Coast Primary Care to perform the treatments or procedures approved by my physician. I acknowledge that no guarantees either expressed or implied, have been made to me regarding the outcome of my treatments and/or procedures. I understand that the nature and purpose of procedures possible alternative methods of treatment and risks involved and the possibilities of complications will be full explained to me prior to any procedures and/or treatments.
Patient/Guardian Signature: _____________________________________________________ Date:_____________
FINANCIAL AGREEMENT: I understand that I am financially responsible for all charges, whether or not paid by said insurance. It is my responsibility to pay any deductible amount due at the time of service or any other balance not paid by my insurance within 30 (thirty) days.
I authorize disclosure of necessary medical information to determine benefits payable to related services. By signing this form, I hereby give
Nature Coast Primary Care consent to perform medical treatment.
Patient/Guardian Signature: _____________________________________________________ Date:______________

Nature Coast Primary Care
Your answers on this form will help your health care provider better understand your medical concerns and conditions. If you are uncomfortable with any question, don’t answer it. Add any notes you think are important.
Main reason for today’s visit: __________________________________________________________________________________
Other concerns: ____________________________________________________________________________________________
Are you allergic to any medications: Yes No
List anything that you are allergic to (medications, food, bee stings etc.) and how each affects you.
Allergy Reaction
1._______________________________________________ _______________________________________________
2._______________________________________________ _______________________________________________
3._______________________________________________ _______________________________________________
Which pharmacy do you use: ______________________________________ City: ________________________________________
Please list all the medications you are taking including inhalers, oxygen, chemotherapy, prescribed drugs, over the counter drugs and vitamins.
Drug Name Dosage How Often When Started
1.___________________________________________________________________________________________________________
2.___________________________________________________________________________________________________________
3.___________________________________________________________________________________________________________
4.___________________________________________________________________________________________________________
5.___________________________________________________________________________________________________________
6.___________________________________________________________________________________________________________
7.___________________________________________________________________________________________________________
8.___________________________________________________________________________________________________________
9.___________________________________________________________________________________________________________
10.__________________________________________________________________________________________________________
Immunizations and most recent date:
□ Chickenpox Date: _____________ □ Meningococcus Date: _________ □Typhoid Date:_________
□ Flu shot Date: ____________ □ MMR (Measles, Mumps, Rubella) Date: _________ □Smallpox Date:_________
□ Gardasil/HPV Date: ____________ □ Pneumonia Date: __________ □Pneumococcal Date:_________
□ Hepatitis A Date: ____________ □ Tdap (tetanus and pertussis) Date: __________
□ Hepatitis B Date: ____________ □ Tetanus Date: __________
□ Zostavax (Shingles) Date: __________
(Other than operations)
Reasons Approximate Dates
Reasons Approximate Dates
________________________________________
________________________________________
________________________________________
____________________________________
__________________________________
____________________________________
Surgery Reason Year Hospital
1.____________________________________________________________________________________________________________
2.____________________________________________________________________________________________________________
3.____________________________________________________________________________________________________________
4.____________________________________________________________________________________________________________

Nature Coast Primary Care
Patient Name: ______________________________ Date of birth:_____________
(Women only)
Last PAP smear__________
Last mammogram__________
Age of first menstrual period__________
Date of last menstrual period or age of menopause__________
Number of pregnancies: ______ Births: ______ Living______
Miscarriages: ______ Abortions: ______
□ Cesarean sections if yes, then number: ______
□ Bleeding between periods
□ Heavy periods
□ Extreme menstrual pain
□ Vaginal itching, burning, or discharge
□ Wake in the night to go to bathroom
□ Hot flashes
□ Breast lump or nipple discharge
□ Sexually active
Current sexual partner is □ Female □ Male
Do you use condoms □ Yes □ No
Other birth control methods used: __________
□ Interested in being screened for STD’S
□ Breast Self Exam
(Please check all that apply)
□ Alcohol Overuse
□ Amputation
□Anemia
□ Anxiety Disorder
□ Arthritis
□ Osteo □ Rheumatoid
□ Asthma
□ Bleeding Disorder (specify)__________
□ Blood Clots (or DVT)
□ Cancer ( Specify) __________
□Cardiac Arrhythmias
Pacemaker _______
□ Chronic Bronchitis
□ Colitis
Specify:_______
□ COPD
□ Coronary Artery Disease
□ Claustrophobic
□ Diabetes – I
□ Diabetes – II
□ Dialysis
□ Emphysema
□ Falls
□ Gout
□ Hepatitis
□ Insulin □ Non-Insulin
□ Heart Attack
□Other Heart Disease (CHF)
□ Hiatal hernia or Reflux Disease
□ HIV or AIDS
□ High Cholesterol
□ High Blood Pressure
□ Kidney Disease
□ Kidney Stones
□ Leg/Foot Ulcers
□ Liver Disease (Specify):________
□ Migraine Headache
□ Mumps
□ Nervous Breakdown
□ Neuropathy
□ Osteoporosis
□ Ostomies
□ Overactive Thyroid
□ Paralysis
□ Polio
□ Pulmonary Embolism
□ Reflux or Ulcers
□ Seizures
□ Sleep Disorder
□ Stroke
□ Tuberculosis
□ Vascular Disease
□ Other
□ Depression
Other conditions: _______________________________________________________________________________________
Have you ever had a cardiac stress test □ Yes □ No If so when:____________
Have you ever had a colonoscopy □ Yes □ No If so when:____________
Do you have a history of drug addiction □ Yes □ No
1) Have you ever smoked? Yes No If Yes, are you a regular smoker now? Yes No
Have you used chewing tobacco? Yes No If Yes, number of yrs. _____ If No, when did you quit?_____
2) Do you regularly drink alcohol? Yes No If Yes, how often:__________________
3) Have you ever used any of the following? Marijuana LSD Heroin Cocaine Speed Other:____________
Relation Alive?
Grandmother (Maternal) Y/N
Grandfather (Maternal) Y/N
Grandmother (Paternal) Y/N
Grandfather (Paternal) Y/N
Father Y/N
Age Significant Health Problems
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke

Nature Coast Primary Care
Patient Name: ______________________________ Date of birth: _________________
Mother Y/N
□ Brother/□ Sister Y/N
□ Brother/□ Sister Y/N
Other: __________ Y/N
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
____ □ Alcoholism □ Arthritis □ Depression □ Cancer □ Diabetes □ Genetic disease
□ Heart disease □ Hypertension □ Osteoporosis □ Stroke
: __________________________
Education - □ Less than 8 th grade □ High school □ 2 Year college □ 4 year college □ Post graduate
Occupation_______________________________________
Is there someone that lives in your residence?
YES If Yes, please list name and relationship:
NO
Type of Residence
Durable Medical Equipment
Can you afford medications
Transportation provided by?
YES
NO
YES
NO
Apartment Mobil Home House: One Story Two Story Assisted Living
Facility Facility Name:_______________________ Other______________
Wheelchair Oxygen Walker Cane Nebulizer
CPAP/BIPAP Other:_________________
Current Weight: ______________Lbs.
Current Diet Plan?
Current Height: ______Ft. ______In Weight Change in the past 6 months? Yes No
Exercise Level
Current Activity
Physical Limitations:
□ None □ Occasional exercise □ Moderate exercise □ High level exercise
How Often
Do you require assistance to bathe or groom?
YES
NO
If Yes, Explain:
Do you require assistance for your toilet needs?
Do you require assistance to eat?
YES
NO
YES
NO
If Yes, Explain:
If, Yes, Explain:
Do you have hearing loss? YES
NO
Do you wear hearing aids? YES NO
Last hearing exam date:
What problems, issues, or medical complaints would you like to address today?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
What would you like to accomplish with your doctor today?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_______________________________________________ ______________________
Patient/Guardian/Parent Signature Date