Patient Registration

INSURANCE INFORMATION
We will request to scan your ID and insurance card and Drivers license.

Secondary InsuranceID

INSURED INFORMATION (IF OTHER THAN PATIENT)

Subscriber/ Policy Holder

Relationship to Patient

RELEASE OF INFORMATION
I hereby give permission to the person listed below to receive information about the above named patient.

Relationship to Patient

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY GRANTING PERMISSION TO TREAT
Just put your initials here!

Occupation, and if retired what was your Occupation?

What is your Passion or Hobby?

MEDICAL INFORMATION
Please list any medications you are currently taking, prescribed or over the counter.
(Ask for extra paper if needed to complete medication list.)

Any ALLERGIES to Medication or Food:

Date of Last Physical Exam

Date of Last Blood Work

Date of Last Menstrual Period

Date of Last Pap Smear

Date of Last Mammogram

Date of Last Dexa Scan

Number of Pregnancies

Date of Last PSA (Prostate Screening Analysis)

If so how many cigarettes/cigars per day

Do you chew tobacco?

Have you thought about quitting?

Have you quit before?

How many drinks in 1 week?

How many drinks in a day?

Drug Use: Any history of illegal drug use?

What activities do you do and how often?

Do you consume any caffeinated products?

Have you recently noticed an increase in sadness or gloominess?

If YOU or a FAMILY MEMBER has had any of the following, please circle and specify
if it is self or family member, and for how long did you have it?

ADD/ADHD

Allergies Anemia Angina Atrial Fibrillation Anxiety Alcoholism Arthritis Asthma Atrial Benign Prostatic Hypertrophy Blood Clots Cancer Cerebrovascular Accident Coronary Artery Disease COPD Crohn’s Disease Depression Diabetes Fractures Gynecological Disease Gallbladder Disease GERD (Reflux) Heart Attack Hepatitis High Blood Pressure High Cholesterol Irritable Bowel Disease Kidney Disease Liver Disease Migraine Neurological Disease Osteopenia/Osteoporosis Peptic Ulcer Disease Respiratory Disease Skin Disease Stomach/Colon Disease Stroke Seizure Disorder Thyroid Disorder Sexually Transmitted Disease

What is the reason for today’s visit?

Are you planning to have blood test done today?

Are you planning to have a B12 shot or Flu shot?

Do you need any refills on your medication today?

Do you have any mild, moderate or severe pain today?

Any other concerns that you would like the Doctor to know?

Do you need to see any specialist, and what kind if any?

Do you prefer Modern Western Medicine, or Holistic and Eastern approach, or Both?

Are you a Religious and a Spiritual person, either or both, or none, or maybe you are Ateist or Agnostic person

Would you like to purchase New Dr. Neskovic's book: "Family Doctor- From Yugoslavian physician to American MD?

Note:
All questions and whole Patient Registration and everything in our office is HIPPA compliant and confidential, and it is information only for you and your doctor, and to help you with your health. Also, all of us in our office will do our best to help you, and we respect equally all of our patients, regardless of sex, race, color, religion or creed.
And just to let you know, I did take Hippocratic Oath, and I take very seriously my calling of being a Family Physician and Geriatrician.
Thank you for choosing our office for all yours and your family medical needs, Dr. Neskovic

Spasoje M. Neskovic, M.D.
Family Practice and Geriatrics- when needed call us always at 818-244 4114, our main office number first, but if something is urgent you can call me at my Private line 818-244 2022.

Ashley, Medical Receptionist call at 818-244 4114
Danika, Medical Assistant call at 818-244 4114

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