Urgent Care Patient Registration and Medical History

Leave this field empty

Before you start

If you have any of these, call 911 now or tell the front desk right away:

Chest pain or pressure, or pain spreading to the arm, jaw or back
Trouble breathing, or lips turning blue or gray
Face drooping, arm or leg weakness, or trouble speaking
Bleeding that will not stop
Swelling of the lips, tongue or throat, or trouble swallowing
Fainting, seizure, or new confusion
Thoughts of harming yourself or others (you can also call or text 988)

Fields marked * are required. Have your photo ID ready when you arrive.

1. Patient information

Last name *

First name *

Middle initial

Date of birth *

Age

What would you like to be called?

First name Last name Other

Other name you go by

Sex assigned at birth *

Male Female

Preferred language

Do you need an interpreter?

Yes No

Street address *

City *

State *

Zip code *

Cell phone *

Home phone

Work phone

Work zip code

Best way to reach you

Call Text Email

How do you get here?

Metro Taxi Walk Drive Ride from someone

Employer

How long employed there

Primary care doctor

Doctor's phone

Doctor's address or clinic

Preferred pharmacy

Pharmacy phone

Emergency contact

Emergency contact name *

Emergency contact relationship *

Emergency contact phone *

If the patient is under 18: parent or legal guardian

Guardian name

Guardian relationship

Guardian phone

How did you hear about us? (check all that apply)

Newspaper Magazine Friend or family Internet search or map Other

Name of newspaper, magazine, friend or other source

2. Reason for today's visit

What is the main reason for your visit today? *

When did it start? (date or number of days) *

Highest temperature (°F), if measured

How did it start?

Suddenly Slowly

Since it started, are you:

Better Same Worse

Pain level right now (0 = none, 10 = worst) *

0 1 2 3 4 5 6 7 8 9 10

Where is the pain?

If you were injured, how did it happen?

What have you tried for it? (medicines, ice, home remedies)

Have you seen anyone else for this problem? Who and when?

3. Allergies and medicines

Do you have any allergies? *

Yes No Not sure

Are you allergic to any of these? (check all that apply)

Penicillin or amoxicillin Sulfa drugs Other antibiotics Aspirin or ibuprofen Codeine or opioids Latex Iodine or X-ray dye Lidocaine or numbing medicine Epinephrine Adhesive tape Metals Eggs Shellfish Peanuts or tree nuts Bee stings

List every allergy and what happens (rash, swelling, trouble breathing)

List all medicines you take, with dose (include inhalers, vitamins, birth control, over-the-counter)

Do you take a blood thinner (such as warfarin, Eliquis, Xarelto, Plavix, daily aspirin)? *

Yes No Not sure

4. Medical history

Have you ever had or been told you have:

ConditionYesNo

Asthma or COPDYesNo

DiabetesYesNo

High blood pressureYesNo

Heart disease or heart attackYesNo

StrokeYesNo

SeizuresYesNo

Kidney diseaseYesNo

Hepatitis, jaundice or liver diseaseYesNo

Bleeding disorder or frequent nosebleedsYesNo

Blood clotsYesNo

CancerYesNo

HIV or weak immune systemYesNo

Autoimmune disorderYesNo

Thyroid diseaseYesNo

Poor wound healing or keloidsYesNo

Depression, anxiety or other mental healthYesNo

Eye problemsYesNo

Problems with anesthesia (you or family)YesNo

Other medical conditions

Past surgeries, with dates

Hospital or ER stays in the past year

Height (estimate is fine)

Weight in lbs (estimate is fine)

Last tetanus shot *

Under 5 years ago 5 to 10 years ago Over 10 years ago Don't know

Flu shot this season?

Yes No

COVID vaccine up to date?

Yes No

5. Symptoms, pregnancy and lifestyle

In the past 2 weeks, have you had any of the following?

SymptomYesNo

General

Fever or chillsYesNo

Feeling very tired or weakYesNo

Weight loss or gain over 10 lbsYesNo

Night sweatsYesNo

Head, eyes, ears, nose, throat

HeadacheYesNo

Eye redness, pain or vision changeYesNo

Ear pain or drainageYesNo

Stuffy nose or sinus pressureYesNo

Sore throatYesNo

Breathing and heart

CoughYesNo

Shortness of breathYesNo

WheezingYesNo

Chest pain or pressureYesNo

Racing or pounding heartbeatYesNo

Swelling in legs or anklesYesNo

Stomach

Nausea or vomitingYesNo

DiarrheaYesNo

Belly painYesNo

Blood in stool or black stoolYesNo

Urine and private areas

Burning or pain with urinationYesNo

Peeing more often than usualYesNo

Blood in urineYesNo

Unusual discharge or bleedingYesNo

Skin

Rash, hives or itchingYesNo

Cut, wound, burn or biteYesNo

Redness, warmth or swelling of skinYesNo

Muscles and bones

Joint or muscle painYesNo

Back or neck painYesNo

Sprain, strain or possible broken boneYesNo

Brain and nerves

Dizziness or faintingYesNo

Numbness or weakness, including faceYesNo

ConfusionYesNo

Mood

Feeling sad, anxious or overwhelmedYesNo

Recent emotional crisisYesNo

For women and girls age 12 and older

Could you be pregnant?

Yes No Not sure

First day of last period

Are you breastfeeding?

Yes No

Number of children

Lifestyle

Do you smoke or vape?

Yes No Quit

If yes, how much and how often?

Do you drink alcohol?

Yes No

Drinks per week

Do you use recreational drugs?

Yes No

Which ones?

Do you feel safe at home? *

Yes No

6. Consent and signature

Consent to treat: I agree to examination, testing and treatment by this clinic's providers and staff, as they judge necessary.

Privacy practices: I have been offered a copy of this clinic's Notice of Privacy Practices.

Privacy notice: We take your privacy and the privacy of our patients very seriously. You agree not to audio record, video record, or take pictures of other patients, staff, physicians, or our facilities. You agree not to disclose information about other patients, staff, physicians, or facilities in any manner or form.

I have read and agree to the consent to treat, privacy practices and privacy notice above. *

May we send a summary of today's visit to your primary care doctor? *

Yes No

Signature: type your full name *

Date *

Relationship to patient (if you are not the patient)