Patient Registration Form
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Nhif 38 issue no. 2 national hospital insurance fund p.o. box 30443 00100 nairobi, kenya. email: info naif.or.ke website: .nhif.or.ke choice of outpatient medical facility form guidelines: 1. principal members are required to forward a duly...
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Patient registration form **today s date: clinic name: patient information: (please use full legal name, no nicknames) *last name: *first name: middle initial: *address: city: state: zip: home phone #: () *social security #: *date of birth: age:...
Patient Registration Form.pdf
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Patient registration form is used in hospitals when a new patient id first admitted. It collects general data about the patient as well as about one's health for the new person's record. It helps the doctor and medical staff to understand the state of health of the individual applying for help. It shows the doctor any previous illnesses, allergic reactions, addictions, etc. It can also contain information about medical insurance (state or paid insurance and the plan). Some clinics focus on certain diseases and may have different more detailed documents. Templates are subdivided into short sections that contain personal data, contacts and insurance details, etc.
The sample contains the following components:
- The full name of the person and date of birth.
- Address and contact information including numbers available during the daytime and a personal number.
- Employment status and family member to contact in case of emergency.
- Detailed information about the current insurance plan.
- Use of alcohul or drugs, smoking, etc.
- Food and medicine allergies and the family history of illnesses (to support or exclude the inheritance factor).
- The past health history and surgical operations including X-ray Chest Diagnosis and hospitalizations.
- The full list of current medications, vitamins, supplements, eye drops, etc.
- The certification of the document and the authorization to release personal information.
The patient registration template is provided by the hospital to the applicant and filed by this person. It is used for collecting medical history and to be available to any doctor.