AutoRemind

Today's Date:

Full Name:

Preferred Name:

Date of Birth (DOB):

Home Address:

City, State:

Zip Code:

Primary Phone Number:

Secondary Phone Number:

Email Address:

Gender Identity/Personal Pronoun(s):

Who Else Lives in Household?

Primary Support Person:

Barriers to Receiving Care:

Housing

Utilities

Food

Transportation

Caregiver/Childcare

Support Network

None

Other

Ethnicity:

Cultural/Religious Beliefs that May Impact Your Care:

Referring Provider:

Primary OB/GYN Provider:

Currently Pregnant?

Yes

No

If Yes, How Many Weeks?

If Yes, Due Date:

Currently Employed?

Yes

No

If Yes, Employer Name:

Type of Work:

Typical Work Hours/Shifts:

Last Grade Completed/Highest Level of Education:

Difficulty with the Following?

Physical Activity

Seeing

Hearing

Reading

Writing

English as Second Language

None

Other

Preference for Method of Learning:

Written Materials

Verbal Discussions

Videos

Other

Tobacco Use:

No, Never

Yes, Currently

Usual Amount Per Week:

Yes, Previously

If Yes, Total Years:

If Yes, Quit Date:

If Yes, Interest in Quitting?

Yes

No

Alcohol Use:

No, Never

Yes, Currently

Type of Alcohol:

Usual Amount Per Week:

Yes, Previously

Type of Alcohol:

Usual Amount Per Week:

Recreational Drug Use:

No, Never

Yes, Currently

Type of Drug:

Usual Amount Per Week:

Yes, Previously

Type of Drug:

Usual Amount Per Week:

Total Number of Years:

Quit Date:

If Yes, Interest in Quitting?

Yes

No

How Would You Rate Your Overall Health?

Excellent

Good

Fair

Poor

Comments:

Emergency

Emergency Contact Name:

Emergency Contact Cell Phone Number:

Emergency Contact Email Address:

Emergency Contact Relationship to Patient:

Insurance Information

Please also email a photo of your insurance card directly to FrontDesk@mertzmfm.com.

Insurance Provider:

Member ID Number:

Group ID Number:

Additional Information

Number of Pregnancies:

Pregnancy History (including Year(s), Gestational Age(s) at Delivery, Mode(s) of Delivery, Gender(s), Birthweight(s), Any Pregnancy Complications)

Current Medications and Doses:

Current Pharmacy:

Known Allergies and Reactions:

Reason for Referral:

Specific Questions/Concerns to Address:

If have a telehealth appointment and would like another person to join from a separate location, please provide the name and email address for this person for receipt of the telehealth link:

Patient or Guardian (where applicable) Name:

Date:

Patient or Guardian (where applicable) Signature:

Please sign electronically below.

New Patient Information Form

Difficulty with the Following?

Preference for Method of Learning:

Tobacco Use:

Alcohol Use:

Recreational Drug Use:

How Would You Rate Your Overall Health?

Emergency

Insurance Information

Additional Information

Patient or Guardian (where applicable) Signature: