Aarogya Aadhar

PATIENT REGISTRATION FORM

Last Name :

First Name:

Middle Name:

Address :

City :

State :

Zip :

Sex :

Age :

Date Of Birth :

Marital Status :

Mobile no :

Second no :

Work :

Aadhar Card No. :

Email ID:

Blood Group :

Emergency Contact (Not Living with you):

Last Name :

First Name:

Relationship to Patient :

Phone :

Alt :

Address :

Patient Photo (Both Side):

Ration Card (Both Side):

HEALTH INSURANCE INFORMATION

Health Insurance :

Yes

Insurance Company Name :

Insurance Number :

Insurance Purchase Date :

Insurance valid Upto :

Personal/Group/Family Policy :

Name of Insured on Card :

Last Name :

First Name:

Middle Name:

Last Insurance Premium Amount :

Benefits Upto :

Attached Your Policy Details :

Medical History Form

Name:

Date Of Birth :

Age :

Sex :

Marital Status :

Race :

Ethnicity :

Language :

Address :

Home Phone :

Occupation :

Work Phone :

If married, spouse’s name :

Children’s names and ages :

Allergies to Medications, X-Ray Dyes, or Other Substances?

Yes

If Yes, please list name of medicine and type of reaction:

name :

reaction :

Medications (Prescriptions, Over-the-Counter, Vitamins, Herbs etc.)

Drug Name :

Dose :

Family History					Check if your blood relatives had any of he following
Relation	Age	State of Health	Age at Death	Cause of Death	Disease	Relationship to you
Father					Arthritis, Gout
Mother					Asthma, Hay Fever
Brothers					Cancer
					Chemical Dependency
					Diabetes
					Heart Disease, Stroke
Sisters					High Blood Pressure
					Kidney Disease
					Tuberculosis
					Other

Prevention
Do you wear seat belts?	Yes	No	If no, why not?
Do you wear a bike helmet?	Yes	No	N/A
Do you exercise regularly?	Yes	No	If yes, duration and number of times per week
Do you smoke?	Yes	No	If yes, how many packs per day
Do you drink alcoholic beverages?	Yes	No	If yes, how much per week
Do you drink coffee?	Yes	No	If yes, how many cups per day
Do you drink tea?	Yes	No	If yes, how many cups per day
If there is a gun in your home, do you keep it unloaded and out of children’s reach?	Yes	No	N/A
Do you use drugs (marijuana, cocaine, etc)?	Yes	No	If yes, explain
Have you ever engaged in any activity that has put you at risk of getting AIDS?	Yes	No	If yes, explain
Do you wish to be tested for AIDS?	Yes	No	If yes, explain
Have you ever worked with chemicals, paints, asbestos or other hazardous material?	Yes	No	If yes, explain
Are you in a relationship in which you have been physically hurt (e.g. slapped, kicked, punched, bruised) by your partner?	Yes	No
Do you ever feel afraid of your partner?	Yes	No	N/A
Do you have a ‘living will’?	Yes	No
Do you have a donor card?	Yes	No
Are you currently using a method of birth control?	Yes	No	If yes, what method

Free services support to Patients & Healthcare Service Providers. Easiest to take and access to best possible your Healthcare needs at one place with affordable amount.

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Aarogya Aadhar

Office Address: Plot No. 344, CTS No. 2537 Parvati, near Old Police Chowki, Sahakar Nagar, Pune, Maharashtra 411009

info@aarogyaaadhar.com

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patient healthcard Form

PATIENT REGISTRATION FORM

HEALTH INSURANCE INFORMATION

Medical History Form

Quick Links

Benifits

Get In Touch

Aarogya Aadhar