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Lisa Nath, MD
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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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If providing an email address would you like to opt into our patient portal

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No

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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:

Not Hispanic or Latino

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?

Yes

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?

Yes

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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Please list any allergies to medications or food:

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Reaction:

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

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

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

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Dose and Frequency:

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Have you ever been diagnosed with the following?

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?

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:

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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