726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
Patient Registration
Guarantor: (If same as patient leave blank)
Home Address:
Emergency Contact:
Contact #1
Contact #2
Are you an Organ Donor? □ Yes □ No
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
Medical History
Your answers to the following questions will help us to understand your medical history and the concerns you would like to discuss with your practitioner. Please fill out as much of this questionnaire as possible. If you can not answer some of the questions or feel uncomfortable answering, leave them blank.
Reason for your appointment:
Medication Allergies:
Environmental Allergies: □ Yes □ No
Are you taking an Aspirin: □ Yes □ No
Please circle to indicate if you have ever had the following conditions: None
□ Alzheimer's Disease
□ Anemia
□ Anxiety
□ Arrhythmia/Palpitations
□ Arthritis/Bursitis
□ Asthma
□ Congestive Heart Failure
□ Constipation/Diarrhea
□ Coronary Artery Disease
□ Depression
□ Diabetes Type I or II
□ Edema
□ Emphysema/COPD
□ Enlarged Prostate
□ GERD/Acid Reflux
□ Gout
□ Heart Attack
□ Hepatitis
□ High Blood Pressure
□ High Cholesterol
□ Incontinence
□ Intestinal Problems
□ Kidney Disease
□ Liver Disease
□ Menopause
□ Migraine Headaches
□ MRSA Infections
□ Osteoporosis
□ Parkinson's Disease
□ Peptic Ulcer/GI Bleed
□ Seizures
□ Stroke
□ Thyroid Disease
□ Tuberculosis
□ Vertigo/Dizziness
□ Cancer
Have you had any Surgeries? □ Yes □ No
If yes, please specify with Date/Year:
Have you had any other medical problems or serious injuries that are not listed above? □ Yes □ No
Who is your Primary Care Provider?
Are you currently seeing any other providers? □ Yes □ No
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
Medical History
Please list all medications, including Vitamins, natural, and prescription medications that you are currently taking. Please note the dosage if possible.
1.
2.
3.
4.
5.
6.
Pharmacy Name, Number, Address:
Have you had any of the following test done? Please note approximate dates.
Pap Smear
Tetanus shot
Mammogram
Influenza
Colonoscopy
Pneumonia
Stress Test
Bone Density
Do you smoke or use tobacco products? □ Yes □ No Quit?
Number of cigarettes daily?
How many years?
Do you drink alcohol? □ Yes □ No
How often?
Do you use recreational drugs? □ Yes □ No
If yes, are you currently using them? □ Yes □ No
Are you sexually active? □ Yes □ No With: □ Men □ Women □ Both
Do you feel like you are at risk of having a sexually transmitted disease? □ Yes □ No
Do you feel at risk for having AIDS/HIV? □ Yes □ No
Are you pregnant? □ Yes □ No Last menstrual cycle?
Have you ever been pregnant? □ Yes □ No
How many times?
Do you use any form of Birth Control? □ Yes □ No
Which Brand?
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
Medical History
Please check any of the Diseases that run in your family and please note who:
| Mother | Father | Sister | Brother | Child | |
|---|---|---|---|---|---|
| Alcohol or Drug use | |||||
| Cancer / Type | |||||
| Diabetes | |||||
| Heart Disease | |||||
| High Blood Pressure | |||||
| High Cholesterol | |||||
| Mental Illness | |||||
| Osteoporosis | |||||
| Stroke | |||||
| Alzheimer's | |||||
| Thyroid problems |
Review of Systems: Are you experiencing any of the following?
Chest pain? □ Yes □ No
Headaches? □ Yes □ No
Nausea? □ Yes □ No
Dizziness? □ Yes □ No
Fatigue? □ Yes □ No
Abdominal Pain? □ Yes □ No
Numbness/Tingling to extremities? □ Yes □ No
Are there any other symptoms you would like to discuss in today's visit?
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
New Patient Welcome Letter
Welcome to Legacy Partners for Equitable Healthcare. We are honored that you have chosen us as your health care provider. Our goal is to provide the highest quality care for all our patients in a timely and respectful manner.
The clinic is managed by a board-certified Nurse Practitioner who holds a Doctor of Nursing Practice Degree which is a terminal clinical practice doctorate that is the highest level of academic preparation. Please note that you may be seen by other health care providers as well. Legacy Partners for Equitable Healthcare does collaborate with other specialists, Nurse Practitioners, and or Physicians should your case require such care.
We will do our best to provide you with same day office visits. You will need to bring your ID and Insurance card with you for each appointment. Please let our office staff know if any of your information changes. If you are unable to provide us with necessary information, your appointment will need to be rescheduled.
All copays and past due balances are expected at time of service, unless a prior agreement has been made with the clinic administrator.
We ask that you allow plenty of time to get to the office for your appointment. You may be asked to reschedule your appointment if you are more than 15 minutes late. We will strive to stay on time. From time to time, a patient emergency arises, and we may be running late for your visit. You will have the option to re-schedule or to stay to be seen and we will keep you informed of how long of a delay you may experience.
Please bring all your prescription and over-the-counter medications with you at each visit.
Our office policy for a missed appointment is:
- If it is an appointment for a new patient, the appointment will not be rescheduled;
- Two (2) no-show appointments will result in dismissal from the practice.
We understand that appointments sometimes need to be changed, so we ask that you call in advance if you cannot keep your scheduled appointment.
Providing the highest quality of professional care to our patients is very important to us. Therefore, the following guidelines for dispensing medications in our office have been established:
- Legacy Partners for Equitable Healthcare does not offer chronic pain management and will not dispense chronic pain medication (for example, chronic daily narcotics). We will provide you with a referral to a pain management center if you need this specialized form of care after evaluation by our healthcare provider (nurse practitioner and/or physician).
- If you are prescribed or taking a psychotropic or controlled substance medication/s you will be required to undergo urine toxicology drug screening and monitoring for your safety.
Patient or Guardian Signature:
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429
Your answers to the following questions will help us to understand your medical history and the concerns you would like to discuss with your practitioner. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering, leave them blank.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
| Not at all | Several days | More often | Nearly daily | |
|---|---|---|---|---|
| 1. Little to no interest/pleasure in doing things? | 0 | 1 | 2 | 3 |
| 2. Feeling down, depressed, or hopeless? | 0 | 1 | 2 | 3 |
| 3. Trouble falling or staying asleep, or sleeping too much? | 0 | 1 | 2 | 3 |
| 4. Feeling tired or having little energy? | 0 | 1 | 2 | 3 |
| 5. Poor appetite or overeating? | 0 | 1 | 2 | 3 |
| 6. Feeling bad about yourself, that you're a failure, or let yourself down? | 0 | 1 | 2 | 3 |
| 7. Trouble concentrating on things, such as reading or watching TV? | 0 | 1 | 2 | 3 |
| 8. Moving or speaking slowly so much that others notice? Or opposite? | 0 | 1 | 2 | 3 |
| 9. Thoughts that you would be better off dead, or harming yourself? | 0 | 1 | 2 | 3 |
| 1. Feeling Nervous, Anxious, or on edge | 0 | 1 | 2 | 3 |
| 2. Not being able to stop or control worrying | 0 | 1 | 2 | 3 |
| 3. Worrying too much about different things | 0 | 1 | 2 | 3 |
| 4. Trouble relaxing | 0 | 1 | 2 | 3 |
| 5. Being so restless that it is hard to sit still | 0 | 1 | 2 | 3 |
| 6. Becoming easily annoyed or irritated | 0 | 1 | 2 | 3 |
| 7. Feeling afraid as if something awful might happen | 0 | 1 | 2 | 3 |
On a scale of 1-10
How many days in the last week have your symptoms caused you to miss school/work or leave you unable to carry out your normal daily responsibilities?
How many days in the last week have you felt so impaired by your symptoms that, even though you went to school or work, your productivity was reduced?
Office use only
726 S Cockrell Hill Rd, Duncanville, TX 75137
Ph: (972) 298-2427 • Fax: (972) 298-2429