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(412) 734-5022

APPOINTMENTS

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Lisa Nath, MD
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(412) 734-5022
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(412) 734-5022

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PATIENT REGISTRATION FORM

Address: 511 Lincoln Avenue Pittsburgh, PA 15202 Phone: 412-734-5022 Fax: 412-766-1316

Patient First Name:

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Patient Last Name:

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Address:

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Apartment #

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City:

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State:

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Zip Code:

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Date of Birth:

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Gender:

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Email:

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Home Phone Number:

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Cell Phone Number:

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Social Security Number:

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Employer:

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Occupation:

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Work Phone Number:

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Special Needs:

Hearing Impaired

Wheelchair

Translator

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Other:

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Race:

American Indian / Alaskan Native

Asian

Black or African American

Middle Eastern

Native Hawaiian / Pacific Islander

White

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Ethnicity:

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Hispanic or Latino

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To whom may we thank for referring you?

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Primary Care Physician:

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Office Address:

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Phone:

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Endocrinologist/Rheumatologist:

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Office Address:

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Phone:

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Emergency Contact #1:

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Relationship:

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Phone Number:

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Emergency Contact #2:

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Relationship:

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Phone Number:

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Pharmacy Name:

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Phone:

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Address:

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Primary Insurance Carrier:

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Subscriber:

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Other:

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Member ID #:

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Group #:

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Secondary Insurance Carrier:

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Subscriber:

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Other:

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Member ID #:

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Group #:

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Do you currently use any recreational drugs?

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No

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Do you currently drink alcohol?

Socially

Everyday Drinker

Non-Drinker

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Smoking Status:

Never

Daily

Former

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Vape?

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No

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Started Smoking:

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Quit Smoking:

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Please list any allergies to medications or food:

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Reaction:

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Reaction:

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Reaction:

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Reaction:

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Please list any current medications or supplements you are currently taking:

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Dose and Frequency:

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Dose and Frequency:

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Dose and Frequency:

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Please list any current medications or supplements you are currently taking:

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Dose and Frequency:

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Dose and Frequency:

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Have you ever been diagnosed with the following?

High Blood Pressure

High Cholesterol

Heart Palpitations

Irregular Heartbeat

Heart Attack

Aneurysm

Abnormal EKG

Asthma

Bronchitis

Emphysema

Hearing Loss

Dizziness/Vertigo

Headache

Allergies

Sinus Problems

Pain with Chewing

Problems Swallowing

Dry Mouth

Heartburn / Acid Reflux

Jaundice

Stroke

Gall Bladder Problems

Kidney Failure

Prostate Problems

Arthritis

Gout

Eczema

Psoriasis

Seizures

Memory Loss

Anxiety/Depression

Multiple Sclerosis

Thyroid Disease

Anemia

Tuberculosis

HIV/AIDS

Cancer

Diabetes

Type

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Last A1C

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Date:

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Do you use Oxygen

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Other:

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Other:

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Have you ever had a family member that was diagnosed with the following?

Glaucoma

Family Member:

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Macular Degeneration

Family Member:

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Please list any past surgeries:

Surgery:

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Date:

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Surgery:

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Date:

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Surgery:

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Date:

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Surgery:

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Date:

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Surgery:

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Date:

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Have you ever had LASIK eye surgery?

Yes

No

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Have you ever had Photorefractive Keratectomy (PRK) eye surgery?

Yes

No

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Lisa M. Nath, MD, LLC

511 Lincoln Avenue

Pittsburgh, PA 15202

(412) 734-5022

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