Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Is the Billing Address Different?
Billing Information
Address Same As Above
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Medical
Primary Medical Insurance Information
Insurance Name:
None
New Insurance
AARP
Aetna Life Insurance
Altius
Banker's
Beech Street Corporation
Blue Cross Blue Shield--Federal Claims
Blue Cross Of Idaho
Blue Cross/blue Shield Of Utah
Blue Shield Of Idaho
Bridgespan
Bureau Of Medicaid Operations
Cigna
Deseret Mutual Healthcare
DirectCare Administrators
EBS-RMSCO (Lifetime Benefit Solutions)
Educators Mutual Insurance
Equitable Insurance Co
EyeMed
Health Choice Utah (IHC)
HEALTH NET FEDERAL SERVICES
Healthy U
Humana
Humana Gold Choice
HUMANA VCP
IBEW
Intermountain Healthcare
LOGISTICS HEALTH INC
Mailhandlers Insurance
Medicare - Noridian Admin Services - Medicare
Met-life Insurance Us West
Miscellaneous Insurers
Operating Engineers Trust Fund
Opticare of Utah Claims Department
OPTUM (AARP & UHC)
Public Employees Health Plan
Railroad Medicare - Medicare
Secure Horizons Direct
Southwest Service Administrators
Tricare West Region
United Healthcare
University of Utah Health Plans
UPREHS
Ut-id Teamsters Security Fund
Utah Pipe Trades Welfare Trust Fund
Vision Service Plan
Worker's Compensation Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First, MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Medical Insurance Information
Insurance Name:
None
New Insurance
AARP
Aetna Life Insurance
Altius
Banker's
Beech Street Corporation
Blue Cross Blue Shield--Federal Claims
Blue Cross Of Idaho
Blue Cross/blue Shield Of Utah
Blue Shield Of Idaho
Bridgespan
Bureau Of Medicaid Operations
Cigna
Deseret Mutual Healthcare
DirectCare Administrators
EBS-RMSCO (Lifetime Benefit Solutions)
Educators Mutual Insurance
Equitable Insurance Co
EyeMed
Health Choice Utah (IHC)
HEALTH NET FEDERAL SERVICES
Healthy U
Humana
Humana Gold Choice
HUMANA VCP
IBEW
Intermountain Healthcare
LOGISTICS HEALTH INC
Mailhandlers Insurance
Medicare - Noridian Admin Services - Medicare
Met-life Insurance Us West
Miscellaneous Insurers
Operating Engineers Trust Fund
Opticare of Utah Claims Department
OPTUM (AARP & UHC)
Public Employees Health Plan
Railroad Medicare - Medicare
Secure Horizons Direct
Southwest Service Administrators
Tricare West Region
United Healthcare
University of Utah Health Plans
UPREHS
Ut-id Teamsters Security Fund
Utah Pipe Trades Welfare Trust Fund
Vision Service Plan
Worker's Compensation Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First, MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Vision
Insurance Information
Insurance Name:
None
New Insurance
AARP
Aetna Life Insurance
Altius
Banker's
Beech Street Corporation
Blue Cross Blue Shield--Federal Claims
Blue Cross Of Idaho
Blue Cross/blue Shield Of Utah
Blue Shield Of Idaho
Bridgespan
Bureau Of Medicaid Operations
Cigna
Deseret Mutual Healthcare
DirectCare Administrators
EBS-RMSCO (Lifetime Benefit Solutions)
Educators Mutual Insurance
Equitable Insurance Co
EyeMed
Health Choice Utah (IHC)
HEALTH NET FEDERAL SERVICES
Healthy U
Humana
Humana Gold Choice
HUMANA VCP
IBEW
Intermountain Healthcare
LOGISTICS HEALTH INC
Mailhandlers Insurance
Medicare - Noridian Admin Services - Medicare
Met-life Insurance Us West
Miscellaneous Insurers
Operating Engineers Trust Fund
Opticare of Utah Claims Department
OPTUM (AARP & UHC)
Public Employees Health Plan
Railroad Medicare - Medicare
Secure Horizons Direct
Southwest Service Administrators
Tricare West Region
United Healthcare
University of Utah Health Plans
UPREHS
Ut-id Teamsters Security Fund
Utah Pipe Trades Welfare Trust Fund
Vision Service Plan
Worker's Compensation Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First, MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Medical History
Personal Medical History:
Unremarkable
Diabetes
High Blood Pressure
Lupus
Rheumatoid Arthritis
Ulcerative Colitis
Reiter's syndrome
Wear A Pacemaker
HIV+
Cancer
Other
Primary Care Physician:
Last Visit:
Reason:
Systemic Meds:
None
Actos
Amaryl
Amiodarone
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
None
Other
No Current Medications
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
Please list all Other Medications:
Drug Allergies:
No Known Drug Allergies
Are you Pregnant or Nursing?:
Yes
No
Family Medical History:
Non-Contributory
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
Hobbies:
Not Specified
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
Tobacco:
No
Yes
Other
Type:
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drugs:
No
Yes
Other
Type:
none
Other
How Long:
STD:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Weight:
lbs.
Height:
ft.
in.
Review of Systems
Do you currently have any symptoms in the following categories?:
General:
None
Fever
Weight Loss
Weight Gain
Other
Skin:
None
pimples, warts
growths
rash
Other
Neurological:
None
numbness, paralysis
headache
seizures
migraines
Other
Endocrine:
None
hypothyroid
hyperthyroid
Hormone Imbalance
Other
Cardiovascular:
None
High BP
Diabetes
Vascular Disease
Surgery
Other
Respiratory:
None
Asthma
Bronchitis
Emphysema
COPD
Other
Bones/Joints/Muscles:
None
joint pain
weakness
stiffness
swelling
cramps
arthritis
Other
Gastrointestinal:
None
stomach upset
diarrhea
constipation
hernia
ulcers
Other
Blood/Lymph:
None
bleeding
anemia
high cholesterol
Other
Allergy/Immune:
None
sneezing
swelling
redness
itching
hives
lupus
Other
Genitourinary:
None
painful urination
frequent urination
impotence
yellow jaundice
Other
Psychiatric:
None
anxiety
depression
insomnia
Other
Ear/Nose/Throat:
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
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