UHZ Sports Medicine Institute


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Part I

Patient Registration

Date / MM / DD YYYY

Body Part

Is this your first visit?

Yes No

Patient Name Title First Last Suffix

DOB / MM / DD YYYY

Address

Street Address Address Line 2 City State Postal / Zip Code

Phone - ### - ### #### Cell Phone - ### - ### ####

International Address

Address Line 1 Address Line 2 Country

International Phone

Sex Female Male

Marital Status Single Married Divorced Widowed

Work
Occupation Employer Address City State Postal / Zip Code Email Address

Phone - ### - ### ####

Work Status Full-Time Part-Time Self Retired

Student Status Full-Time Part-Time

School Name

If minor, parent or guardian contact information: Phone - ### - ### ####

Emergency Contact Name: Phone - ### - ### ####

Family Physician: Phone - ### - ### ####

Who referred you to us?

Part II

Patient Name Title First Last Suffix

DOB / MM / DD YYYY Age

Physician you are here to see

Injury related to Medical School Auto Other

Date of Injury / MM / DD YYYY Chief Complaint Left Right

Body Part

Please Describe Injury

Recent Surgery or Illness and Dates:

Surgery/Illness:        Date:
Surgery/Illness:        Date:
Surgery/Illness:        Date:

Allergies:

Medications you are currently taking:

Do you have a history of:    Asthma Bleeding Disorder Cardiac

Diabetes Hepatitis Hypertension

Tuberculosis Smoking  (Quantity: )

Alcohol Consumption  (Quantity:) Other

Referred by: Is he/she a physician? Yes No Address:

Patient Signature (Firma del Paciente): Date:

Section I: Is the reason for the visit to your doctor due to:

Medical-Related Illness:
*If yes, you do not need to answer the questions below.
Yes No
Accident-Related Injury:
*If yes, please check one of the categories in #1 and complete items 2 and 3.
Yes No
1. Auto: Home School Work Other

Specify Where:

2. Date of Accident:

3. How did the accident happen?:

Was a third party responsible for your injury?:
*If yes, provide the following below:
Yes No

Name of individual and/or company:

Name and address of attorney representing third party, insurance company or party responsible:

Section II:

1. Were you in your own vehicle or someone else's vehicle?

2. Name of insurance company and telephone number:

3. Policy #: Accident Claim #:

4. Amount of PIP Coverage: Deductible:

5. Are you represented by an attorney?: Yes No

Phone Number:

Patient Signature (Firma del Paciente): Date:

Please Download and Sign the following Consent Forms

Content for Treatment
Consent for Treatment - Spanish
Notice of Privacy

For Appointmets Call UHZ Sports Medicine Institute: 786-268-6208

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