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Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Patient Registration( * mandatory to fill )

EMERGENCY CONTACT INFO( * mandatory to fill )

Insurance Information( * mandatory to fill )

Our office will require a copy of your insurance card(s) for our records.
I authorize the release of all medical information necessary to process my claims for services provided by comprehensive kidney care. I also request that payment for these services be made directly to 610 S Maple Ave #4100, Oak Park, IL 60304.
SIGNATURE
 
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Medical History

Which of the following disease yo have ?

Family Kidney History

Social History

Patient Medical Information

Any Family History of:

High Blood Pressure
Yes
No
Diabetes
Yes
No
Anemia
Yes
No
Cancer
Yes
No
High Cholesterol
Yes
No
Kidney Stones
Yes
No
Cysts in Kidney
Yes
No
Anyone on Dialysis?
Yes
No
Lupus-Autoimmune Disorders
Yes
No
AIDS or AIDS Related
Yes
No
Asthma
Yes
No
Hereditary Kidney Condition
Yes
No
Heart Disease
Yes
No
Liver Disease
Yes
No
Vein or Artery Disease
Yes
No
Lung Disease
Yes
No
Gastrointestinal Disease
Yes
No
Protein or Blood in Urine
Yes
No
Potassium Wasting
Yes
No
Problems with Pregnancy
Yes
No

 

Kidney Transplant
Yes
No
Kidney Removal
Yes
No
Any Ultrasound or Imaging of your kidney?
Yes
No
Taking NSAID's (Aleve, Tylenol, or Ibuprofen)?
Yes
No
Any recent CAT scan or MRI with contrast?
Yes
No
Drink Alcohol?
Yes
No
Using Street Drugs?
Yes
No
Tobacco Use?
Yes
No
Taking Herbal Supplements?
Yes
No
Any Recent Antibiotics?
Yes
No
Allergies? Food, Drugs or Environment?
Yes
No
Do you have a "Do not Resuscitate Order" in place
Yes
No

Are you experiencing?

Metallic Taste in morning?
Yes
No
Lower Extremity Swelling?
Yes
No
Rashes? Bruising?
Yes
No
Shortness of Breath?
Yes
No
Anemia? Loosing Blood?
Yes
No
Uncontrolled Blood Pressure?
Yes
No
Lead Exposure?
Yes
No
Bleeding Disorders?
Yes
No
Stroke Vascular Disease?
Yes
No
Excessive Urination at Night?
Yes
No
Poor Urinary Stream?
Yes
No
Frequent Urination Burning?
Yes
No
Foam in Urine?
Yes
No
Heat or Cold Intolerance?
Yes
No
Confusion?
Yes
No
Hearing Loss?
Yes
No
Abdominal or Flank Pain?
Yes
No
Appetite Poor?
Yes
No
Joint Pains? Arthritis? Where?
Yes
No
Weight Gain or Weight Loss?
Yes
No
Swelling in Legs or Ankles?
Yes
No
Changes in Urination?
Yes
No
Blood in Urine?
Yes
No
Visual Problems?
Yes
No
Dizziness or Light-Headaches?
Yes
No
Nausea or Vomiting?
Yes
No
Difficulty with Breathing?
Yes
No
Pain in Legs after walking?
Yes
No
Sleep Disturbances?
Yes
No
Skin Rash Itching?
Yes
No
Fatigue or Weakness?
Yes
No
Kidney stones?
Yes
No
Problems with Pregnancy?
Yes
No
Psych Problems (Lithium use)?
Yes
No
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Comprehensive Kidney Care. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title: Last Name: First Name: Middle Name: Date Of Birth: Social Security Number: Gender: Street Address: City: State: Zip: Mobile Number: Work Phone: Patient's employer: Telephone: Spouse Name: Telephone: Email Address:
Race:
White/Caucasian Hispanic Asian African American Native Hawaiian Other
Specify, If Other?

Emergency Contact Info

Notify in case of emergency name and number
Name: Number: Family Physician: Telephone:

Insurance Information

Primary Insurance Company: Insured Name: Effective Date of policy: Policy#: Group#: Primary Insurance Mailing Address: Zip Code: Telephone: Secondary Insurance Company: Insured Name: Effective Date of policy: Policy#: Group#: Secondary Insurance Mailing Address: Zip Code: Telephone:
Our office will require a copy of your insurance card(s) for our records.
I authorize the release of all medical information necessary to process my claims for services provided by comprehensive kidney care. I also request that payment for these services be made directly to 610 S Maple Ave #4100, Oak Park, IL 60304.
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Medical History
Name: PCP: DOB: Other Specialists: Past Medical History(with duration):
Which of the following disease yo have ?
Diabetes / Diabetic Retinopathy HTN CHF CAD
CKD/Previous Baseline Cr Nephrolithiasis Renal Cysts Proteinuria
Hematuria Liver Dx Rashes/Joint Pain Recent Abx
NSAIDS CT/MRI w/Contrast Renal U/S Vascular Dx
Other
Past Surgical History:

Family Kidney History

Mom: Dad: Siblings: Kids: Allergies: Medications:

Social History

Tob/ETOH/Illicits: Employment: Residence & Other:
Patient Medical Information
List any medical problems and duration: Surgical Procedures with Dates:

Any Family History of:

High Blood Pressure
Yes
No
Relationship:
Diabetes
Yes
No
Relationship:
Anemia
Yes
No
Relationship:
Cancer
Yes
No
Relationship:
High Cholesterol
Yes
No
Relationship:
Kidney Stones
Yes
No
Relationship:
Cysts in Kidney
Yes
No
Relationship:
Anyone on Dialysis?
Yes
No
Relationship:
Lupus-Autoimmune Disorders
Yes
No
Relationship:
AIDS or AIDS Related
Yes
No
Relationship:
Asthma
Yes
No
Relationship:
Hereditary Kidney Condition
Yes
No
Relationship:
Heart Disease
Yes
No
Relationship:
Liver Disease
Yes
No
Relationship:
Vein or Artery Disease
Yes
No
Relationship:
Lung Disease
Yes
No
Relationship:
Gastrointestinal Disease
Yes
No
Relationship:
Protein or Blood in Urine
Yes
No
Relationship:
Potassium Wasting
Yes
No
Relationship:
Problems with Pregnancy
Yes
No
Relationship:
Any complications or problems not listed anywhere else?
Kidney Transplant
Yes
No
Kidney Removal
Yes
No
Are your Parents Alive? Cause of Death Who do you live with? How many siblings or kids do you have? What type of work do you do?
Any Ultrasound or Imaging of your kidney?
Yes
No
Taking NSAID's (Aleve, Tylenol, or Ibuprofen)?
Yes
No
Any recent CAT scan or MRI with contrast?
Yes
No
Drink Alcohol?
Yes
No
Using Street Drugs?
Yes
No
Tobacco Use?
Yes
No
How long?
Taking Herbal Supplements?
Yes
No
Name them:
Any Recent Antibiotics?
Yes
No
How long?
Allergies? Food, Drugs or Environment?
Yes
No
Name them
Do you have a "Do not Resuscitate Order" in place?
Yes
No
List medications with doses that currently on:

Are you experiencing?

Metallic Taste in morning?
Yes
No
How long?
Lower Extremity Swelling?
Yes
No
How Long?
Rashes? Bruising?
Yes
No
How Long?
Shortness of Breath?
Yes
No
How Long?
Anemia? Loosing Blood?
Yes
No
How Long?
Uncontrolled Blood Pressure?
Yes
No
How Long?
Lead Exposure?
Yes
No
How Long?
Bleeding Disorders?
Yes
No
How Long?
Stroke Vascular Disease?
Yes
No
How Long?
Excessive Urination at Night?
Yes
No
How Long?
Poor Urinary Stream?
Yes
No
How Long?
Frequent Urination Burning?
Yes
No
How Long?
Foam in Urine?
Yes
No
How Long?
Heat or Cold Intolerance?
Yes
No
How Long?
Confusion?
Yes
No
How Long?
Hearing Loss?
Yes
No
How Long?
Abdominal or Flank Pain?
Yes
No
How Long?
Appetite Poor?
Yes
No
How Long?
Joint Pains? Arthritis? Where?
Yes
No
How Long?
Weight Gain or Weight Loss?
Yes
No
How Long?
Swelling in Legs or Ankles?
Yes
No
How Long?
Changes in Urination?
Yes
No
How Long?
Blood in Urine?
Yes
No
How Long?
Visual Problems?
Yes
No
How Long?
Dizziness or Light-Headaches?
Yes
No
How Long?
Nausea or Vomiting?
Yes
No
How Long?
Difficulty with Breathing?
Yes
No
How Long?
Pain in Legs after walking?
Yes
No
How Long?
Sleep Disturbances?
Yes
No
How Long?
Skin Rash Itching?
Yes
No
How Long?
Fatigue or Weakness?
Yes
No
How Long?
Kidney stones?
Yes
No
How Long?
Problems with Pregnancy?
Yes
No
How Long?
Psych Problems (Lithium use)?
Yes
No
How Long?
Signed Name Printed Name Who referred you to our office? Who is your primary care physician?
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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