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Mitchell County Hospital

Patient Pre-registration Application

This form is to register for our Patient Pre-registration Program. By registering with us you can receive peace of mind that we have your medical information.
Please Print clearly and Complete the following information. This form should take 5 to 10 minutes to complete.
* Patient Full Name
First Name, Middle Initial, Last Name
* Primary Physician
* Today's Date
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* Telephone
Area Code and 7 Digit Number
* Email Address
* Date of Birth
* Marital Status Single     Married     Divorced    
* Sex Male     Female    
* Race Black     White     Asian     Indian    
* Social Security Number
Nine Digit Social Security Number
* Religion
* Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
* Responsible Party Information
Fill Out Below If The Patient Is Not The Resonsible Party
If Patient Above Is Responsible Party Then Check This Box
* Person Responsible For Bill
  Date of Birth
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone
Area Code and 7 Digit Number
  Sex Male     Female    
  Relationship To Patient
  Social Security Number
Nine Digit Social Security Number
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Responsible Party's Occupation
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
* Insurance or Medicare/Medicaid Numbers
Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.
* Drug Allergies
Please list all drugs and types of reaction
* Do you Smoke? yes
no
* If so:
How many packs? Years Smoking? Have you stopped? Would you like Cessation Education?
* Do you use other Tobacco products? yes
no
* If so:
What product? How long? Have you stopped?
* Do you drink Alcohol? yes
no
* If so:
How long? Last drink? Have you stopped?
* Do you use illegal Drugs? yes
no
* If YES, what kind?
* Do you drink caffeine?
* If YES, how much?
Family History
Please indicate if any of your blood relatives have or have had any of the following:
*
Check all that apply
Aids or HIV
Arthritis
Asthma
Bleeding Disorder
Bowel Disease
Cancer
Chemical Dependency
Depression
Diabetes
Epilepsy/Convulsions
Glaucoma
Eye Disease
Heart Disease
High Blood Pressure
Kidney Disease
Lung Disease
Psychiatric Care
Stroke
Thyroid Problems
Tuberculosis
Other:
*
If checked, please indicate the illness and your relationship to the relative.
Problem List
Please check all medical conditions you have or have had in the past:
*
Check all that apply
Chronic Pancreatitis
Cirrhosis
Crohns
Lupus Erythematosus
Myasthenia
Multiple Sclerosis
Alcoholism
Arthritis
Asthma
Aids/HIV
Anemia
Anxiety
Bleeding Disorder
Breast Mass
Bronchitis
Bulima
Cancer
Chemical/Drug Dependent
Clotting Problems
Colitis
Deep Vein Thrombosis
Back Pain
Blood Clots
Breast Cancer
Colon Cancer
Depression
Diabetes/Pre-Diabetes
Esophageal Dysmotility
Gallbladder Disease
Heart Disease
Emphysema
Epilepsy
Gibromyalgia
Goiter
Gonorrhea
Gout
Heart Murmur
Hepatitis
Herpes
Immune System Disorder
Irregular Heart Beat
Irritable Bowel
Heartburn/Reflux
Hiatal Hernia
High Blood Pressure
High Cholesterol
High Triglycerides
Hip Problems
Knee Problems
Ankle Problems
Foot Problems
Infertility
Liver Disease
Kidney Disease
Migraines/Headaches
Pace Maker
Pneumonia
Prostrate Problems
Psychiatric Care
Pulmonary Embolism
Reaction to Anesthesia
Rheumatic Fever
Scleroderma
STD
Polyscystic Ovarian Syndrome
Prostrate Cancer
Shortness of Breath w/Exertion
Sleep Apnea
Stroke
Thyroid Disease
Urinary Stress Incontinence
Uternine Cancer
Varicose Veins
Seizure Disorder
Sinus Infections
Sjogrens Syndrome
Stomach Ulcers
Suicide Attempts
Thyroid Problems
Tuberculosis
Vaginal Infections
Venereal Disease
Other
* Surgical History
Please list all surgical procedures you have had in the past. Include the name/type of operation and the year the procedure was conducted.
* Preferred Pharmacy
Please give name, location, and phone #.
* Current Medications
List Drug name, dose, frequency, route, and reason for taking. Include Herbal and Over the Counter Medications.