Jennifer Lilly Patient Registration
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Welcome

 

Thank you for choosing Jennifer Lilly as your mental health care provider. Our goal is to provide you with the best possible service that will help you reach your goals.

Physician & Office Location

Office Location
Preferred Provider

Patient Information

Reason For Visit
First Name
Middle Initial
Last Name
Suffix
Date of Birth //MM/DD/YYYY
Social Security Number --Numbers only, no special characters
Salutation
Street Address
City
State
Zip -
Country
Home Phone --
Cell Phone --
Work Phone --
Work Phone Extension
Email @I do not have an email account
Gender
Ethnicity
Nickname
Marital Status
Employer Name
Occupation
Who shall we contact in case of an emergency?
First Name
Last Name
Relationship
Home Phone --
Cell Phone --
Work Phone --

 

Account Responsible Information

Click here to copy information from the Patient Information Section

First Name
Middle Initial
Last Name
Date of Birth //MM/DD/YYYY
Social Security Number --Numbers only, no special characters
Salutation
Street Address
City
State
Zip -
Relationship
Home Phone --
Cell Phone --
Work Phone --
Work Phone Extension
Email @I do not have an email account
Gender

 

Medical Insurance Information

Click here to copy information from the Patient Information Section

Click here to copy information from the Account Responsible Section

Insurance Company Name
Insurance Street
Insurance City
Insurance State
Insurance Zip -
Subscriber First Name
Subscriber Last Name
Subscriber Middle Initial
Subscriber Suffix
Subscriber Date of Birth //MM/DD/YYYY
Salutation
Subscriber Street Address
Subscriber City
Subscriber State
Subscriber Zip -
Subscriber Phone --
Subscriber Gender
Policy ID
Group Number
Group Name
Subscriber Employer/ School
Relationship to Subscriber

Insurance Company Name
Insurance Street
Insurance City
Insurance State
Insurance Zip -
Subscriber First Name
Subscriber Last Name
Subscriber Middle Initial
Subscriber Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Subscriber Street Address
Subscriber City
Subscriber State
Subscriber Zip -
Subscriber Phone --
Subscriber Gender
Policy ID
Group Number
Group Name
Employer/ School
Relationship to Subscriber

Insurance Company Name
Insurance Street
Insurance City
Insurance State
Insurance Zip -
Subscriber First Name
Subscriber Last Name
Subscriber Middle Initial
Subscriber Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Subscriber Street Address
Subscriber City
Subscriber State
Subscriber Zip -
Subscriber Phone --
Subscriber Gender
Policy ID
Group Number
Group Name
Employer/ School
Relationship to Subscriber

 

Referral Information

Please tell us how you heard about our services

Referral Source: 
Description\Name: 

 

Medications

Please list all medications you are currently taking

Medication Name Date Started (mm/dd/yyyy) Use

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Allergies

 

Name of Allergy Reaction Severity Onset Type










 

Surgeries

 

Date of Surgery (mm/dd/yyyy) Surgeon Name of Procedure
/ / MM/DD/YYYY

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General History

 

Who is your Primary Care Physician?
Last Visit to PCP
Reason for Visit to PCP
Last Eye Exam //MM/DD/YYYY
Dr Last Eye Exam

 

Health Review

Please select entries from the drop down boxes. To select more than one entry from a drop down, hold down the control key as you click on the list items.

Click here to mark all items as 'Negative'

Endocrine
Negative
Adrenal Gland Disorders
Diabetes - Diet Controlled
Diabetes - Gestational
Diabetes Type I
Diabetes Type II
Hpyerthyroidism
Hypoglycemia
Hypothyroidism
Prediabetes
Other:
Hematologic/ Lymphatic
Negative
Anemia
Blood Disorders
Enlarged Lymph Nodes
Hemachromatosis
Hemophilia
Leukemia
Lyme Disease
Lymphoma
Other:
Cardiovascular/ Heart
Negative
Angina
Arrhythmia
Bypass Graft
Bypass Surgery
Chest Pain
Congestive Heart Failure
Coronary Artery Disease
Cyanosis
Heart Disease
Heart Murmur
Heart Palpitation
High Blood Pressure Controlled
High Blood Pressure Uncontrolled
High Cholesterol
History Of Heart Disease
Irregular Heart Beat
Mitral Valve Prolapse
Pacemaker
Shortness Of Breath
Stent
Stroke
Valve Replacement
Other:
Neurological
Negative
Bell's Palsy
Cranial Nerve Palsy
Dizziness
Epilepsy
Involuntary Movement
Migraines
Paralysis
Seizures
Stroke
TIA
Vertigo
Other:
Ears, Nose, Throat
Negative
Chronic Colds
Chronic Sinusitis
Chronic Strep Infections
Dentures
Ear - Itching
Ear Infections
Ear Pain
Hearing Aid Both Ears
Hearing Aid Left Ear
Hearing Aid Right Ear
Hearing Loss Left Ear
Hearing Loss Right Ear
Mouth Sores
Nose Bleeds
Partial Hearing Loss Both Ears
Partial Hearing Loss Left Ear
Partial Hearing Loss Right Ear
Ringing In Ears
Runny Nose
Sinus Pain
Sinusitis
Sore Throat
Stuffy Nose
Other:
Respiratory/ Lungs
Negative
Asthma
Bronchitis
Chronic Bronchitis
Chronic Cough
Collapsed Lung Left
Collapsed Lung Right
COPD
Cough
Emphysema
Lung Cancer
Pleurisy
Pneumonia
Sarcoid
Shortness Of Breath
Tuberculosis
Other:
Stomach/ Intestines
Negative
Abdominal Pain
Bowel Cancer
Change In Appetite
Constipation
Crohn's Disease
Diarrhea
Difficulty Swallowing
Diverticulitis
Esophagitis
Frequency Of Bowel Movements
Gall Bladder Disease
Gastric Reflux
Heartburn
Hemorrhoids
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Hernia
Indigestion
Irritable Bowel Syndrome
Jaundice
Nausea
Pancreatitis
Stomach Cancer
Ulcerative Colitis
Ulcers
Other:
Integumentary/ Skin
Negative
Basal Cell Carcinoma
Bruising
Changes In Color/ Pigementation
Changes In Nails/ Hair
Dermatitis
Dryness
Eczema
Excessive Sweating
Itching
Psoriasis
Skin Cancer
Skin Rash
Other:
Bones/ Joints/ Muscles
Negative
Arthritis
Back Pain
Bone Cancer
Cerebral Palsy
Gout
Joint Pain
Juvenile Rheumatoid Arthritis
Limited Range Of Motion
Multiple Sclerosis
Muscle Pain
Muscular Dystrophy
Neck Pain
Polymyalgia
Rheumatoid Arthritis
Other:
Allergic/ Immunologic
Negative
Allergy Shots
HIV
Immune Disorder
Lupus
Seasonal Allergies
Other:
Psychiatric
Negative
Childhood Trauma
Depression
Panic Episodes
Stress
Other:
Genitals/ Kidney/ Bladder
Negative
Bladder Infections
Bladder Repair
Bladder Spasms
Cervical Cancer
Changes In Color Of Urine
Dialysis
Endometriosis
Frequent Urination
Incontinence
Kidney Failure
Kidney Infections
Kidney Stones
Kidney Transplant
Menopause Symptoms
Ovarian Cancer
Ovarian Cysts
Prostate Cancer
Recurrent Urinary Tract Infections
Renal Cancer
Renal Stricture
Sexually Transmitted Disease
Testicular Cancer
Uterine Cancer
Uterine Fibroids
Other:
Constitution
Negative
Chills
Fatigue
Fever
Insomnia
Sleeping All The Time
Sudden Weight Gain
Sudden Weight Loss
Weakness
Other:
Other
Other:
Past Medical Conditions
Details of Past Medical Conditions

 

If Diabetic

 

When were you diagnosed as diabetic?
Type of Diagnosis?
Blood Sugar
Date of Last Blood Sugar //MM/DD/YYYY
Self Monitoring Blood Sugar YesNo
HbA1C .
HbA1C Date //MM/DD/YYYY

 

Ocular History

 

Wear Glasses or Contacts
Other

 

Social History

 

Do you smoke?
Do you drink alcohol?
Recreational Drug Use
Occupation
Hobbies
Fishing
Piano
Pilot
Sewing
Sports
Other:

 

Review and Submit

You may print a copy of this document directly from your web browser or you may request a copy from our receptionist. By checking the box below, I acknowledge that I have reviewed the Patient Information Packet in its entirety and that I have the right to ask questions regarding the information contained therein prior to initiating treatment.
Click Here I have read the Privacy Statement


 

Psyquel
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