New Patient Registration - Miami Dade Medical & Rehabilitation Center

New Patient Registration & Medical History

Please complete all sections below. This information helps us provide you with the best possible care. All fields marked with * are required and all information is kept strictly confidential.

1. Personal Information

First Name *

Last Name *

Date of Birth *

Gender *

Phone Number *

Email Address *

Street Address *

City *

State *

ZIP Code *

2. Emergency Contact

Full Name *

Relationship *

Phone Number *

3. Insurance Information

Insurance Provider

Member ID / Policy Number

Group Number

Policy Holder Name

4. Reason for Visit

What is your main reason for visiting today? *

When did it start?

Pain Level (0 = none, 10 = worst)

5. Past Medical History

Please check all conditions you have been diagnosed with:

Diabetes Hypertension Heart Disease Asthma / COPD Cancer Stroke Arthritis Depression / Anxiety Thyroid Disorder Kidney Disease Liver Disease Osteoporosis

Other diagnosed conditions not listed above:

6. Surgical History

Have you had any surgeries or hospitalizations? Please list them with approximate dates:

7. Medications & Allergies

Current Medications (include dosage if known): *

Drug / Food Allergies: *

8. Family Medical History

Please check conditions that run in your immediate family (parents, siblings, children):

Diabetes Hypertension Heart Disease Cancer Stroke Depression / Anxiety

Other family history not listed:

9. Social History

Smoking / Tobacco Use

Alcohol Use

Exercise Frequency

Occupation

10. Current Symptoms

Please check any symptoms you are currently experiencing:

Fatigue Headaches Dizziness Chest Pain Shortness of Breath Joint / Muscle Pain Back Pain Numbness / Tingling Nausea / Vomiting Sleep Problems Depression / Anxiety Unexplained Weight Change

Any additional symptoms or concerns:

11. Provider Information

Primary Care Physician

Referred By

12. Consent & Acknowledgment

I acknowledge that I have received and read the Privacy Policy and consent to the use and disclosure of my health information as described. *

I certify that all information provided in this form is true and accurate to the best of my knowledge. *

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