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The form gathers medication lists, allergies, and structured yes/no screening across systems (ENT, chest, cardiovascular, GI, GU, metabolic, joints, nerves) plus family health history and, for women, reproductive history. It also includes insurance responsibility consent and patient signature/initial areas for required authorizations.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/new-patient-health-information-please-downloadprint-return-instructions/564110/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/new-patient-health-information-please-downloadprint-return-instructions/564110.png","ImageObject",442,249,{"name":42,"@type":43},"How to eat","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-16","2026-10-12",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information must a new patient provide in this packet?","Question",{"text":62,"@type":63},"The packet requests demographics, primary care history, reason for changing physicians, current medical issues, past history, medication list, allergies, and structured health screening answers.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How are current medical issues and past history recorded?",{"text":67,"@type":63},"Current problems are listed with duration in a table, and past serious illnesses, injuries, and operations are recorded in a procedure/illness table with the year.",{"name":69,"@type":60,"acceptedAnswer":70},"What insurance and authorization statements are included?",{"text":71,"@type":63},"The form states it files primary and secondary insurance only, confirms coverage, explains financial responsibility for changes, authorizes release of information to secure benefits payment, and allows use of the signature on insurance submissions. It also specifies that co-pays, co-insurance, and deductibles are due the day of service.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},564110,1792111841,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":22,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":109,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":140},962093541613,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","George E. Thomas, MD Jeremy Huff, DO John T. Fowler, MD Maria S. Blahey, MD Santos M. Soberon, MDRawan Musa, MD Chad Hammett, MD Waqar Ahmad, MD Mustafa I. Musa, MD Gwendolyn Lavalais, MD  \n755 N 11 th Street, Suite P-5200, Beaumont, TX 77702 • Ph: 409-898-2994 • Fax: 409-898-2592 • [www.bimga.com](www.bimga.com)  \nPLEASE DOWNLOAD/PRINT & RETURN-INSTRUCTIONS ON LAST PAGE  \nNEW PATIENT HEALTH INFORMATION  \n(PLEASE USE BLUE OR BLACK INK)  \nDOCTOR:   TODAY’S DATE:    \nNAME:   DATE OF BIRTH:    \nEMAIL:   SOCIAL SECURITY \\#:   ADDRESS:   CITY/STATE:   ZIP:   PHONE \\#:   ALTERNATE \\#:   REFERRED BY:   MARITAL STATUS: (CIRCLE ONE) SINGLE MARRIED WIDOWED DIVORCED EMPLOYER:   PHONE:   NEAREST RELATIVE:   PHONE:   RELATIONSHIP:    \nPREVIOUS PRIMARY CARE PHYSICIAN:   HAVE YOU SEEN YOUR PRIMARY CARE PHYSICIAN IN THE LAST 2 YEARS? YES or NO HOW OFTEN DO YOU SEEYOUR PRIMARY CARE PHYSICIAN?    \nREASON CHANGING PHYSICIANS:   HAVE YOU EVER BEEN DISCHARGED FROM ANOTHER PRACTICE? YES or NO  \nDO YOU CHANGE PHYSICIANS FREQUENTLY? YES or NO  \nHOW MANY TIMES HAVE YOU BEEN ADMITTED TO THE HOSPITAL IN THE LAST YEAR?   WHAT SPECIALISTS DO YOU SEE?    \nINSURANCE NAME:   INSURANCE PHONE \\#:   MEMBER ID \\#:   GROUP \\#:    \nIT IS REQUIRED FOR YOU TO COMPLETE ALL THE TABLES BELOW. IF IT DOESN’T APPLY STATE  \n“NONE”.  \n•PRESENT ILLNESS: List your primary ailments as of today and how long you have had them.  \n\n| Current Medical Issues | How Long? |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\n•PAST HISTORY: List all serious illnesses, injuries and operations.  \n\n| Procedure/Illness | Year |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\n•List ALL medications including vitamins/herbal supplements.  \n\n| Name of Medication | Dosage | Prescribing Physician |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\n\n|  |  |  |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\nALLERGIES:   Circle YES or NO to the following questions.  \nEAR, NOSE & THROAT:  \nDo you have any type of eye disease? YES NO  \nDo you have any type of ear disease? YES NO  \nDo you have any type of hay fever or sinus trouble? YES NO  \nDo you have frequent sore throats? YES NO  \nCHEST:  \nHave you ever had a chronic chest condition?  \n(Such as asthma, bronchitis, etc.?)   YES NO  \nDo you smoke? Pack/day?   YES NO  \nCARDIOVASCULAR:  \nHas a Dr. ever said that you had heart trouble? YES NO  \nHas a Dr. ever said that you have high blood pressure? YES NO  \nHave you ever had rheumatic fever? YES NO  \nDo you get tired easily or short of breath? YES NO  \nDo your ankles swell at times? YES NO  \nGI:  \nDo you suffer from upset stomach? YES NO  \nHas a doctor ever said you had an ulcer? YES NO  \nDo you drink alcoholic beverages? YES NO  \nDo you partake in recreational drugs? YES NO  \nHave your bowel habits changed in the past year? YES NO  \nGU:  \nHave you ever had kidney disease or infection? YES NO  \nHave you had frequent urinary tract infections? YES NO  \nMETABOLIC:  \nDo you have diabetes? YES NO  \nDo you have excessive thirst? YES NO  \nDo you have excessive urine output? YES NO  \nDo you have thyroid trouble? YES NO  \nJOINTS:  \nAre your joints often painful or swollen? YES NO  \nNERVES:  \nHave you ever had a nervous breakdown? YES NO  \nDo you seem to be tense and nervous all the time? YES NO  \nHave you ever been a patient in a mental health facility? YES NO  \nFAMILY HISTORY:  \nPLEASE CIRCLE THE STATE OF HEALTH FOR THE FOLLOWING PEOPLE.  \nIF DECEASED PLEASE GIVE THE CAUSE OF DEATH:  \nSPOUSE:  GOOD  \nFATHER:  GOOD  \nMOTHER:  GOOD  \nSISTERS:  GOOD  \nBROTHERS: GOOD  \nFAIR  \nFAIR  \nFAIR  \nFAIR  \nFAIR  \nPOOR  \nPOOR  \nPOOR  \nPOOR  \nPOOR  \nDECEASED: CAUSE OF DEATH:   \nDECEASED: CAUSE OF DEATH:   \nDECEASED: CAUSE OF DEATH:   \nDECEASED: CAUSE OF DEATH:   \nDECEASED: CAUSE OF DEATH:   \nHAS ANYONE IN YOUR FAMILY HAD ANY OF THE FOLLOWING DI","cbCaio2BXGnuMiqO","https://ap.wps.com/l/cbCaio2BXGnuMiqO","pdf",241011,"English","# New Patient Health Information\n## Patient demographics and physician information\n## Medical history and current conditions\n## Medications and allergies\n## Health screening questions (YES/NO)\n## Family history and women-only questions\n## Insurance filing statements and patient authorization\n## Required initials and signatures","[{\"question\":\"What information must a new patient provide in this packet?\",\"answer\":\"The packet requests demographics, primary care history, reason for changing physicians, current medical issues, past history, medication list, allergies, and structured health screening answers.\"},{\"question\":\"How are current medical issues and past history recorded?\",\"answer\":\"Current problems are listed with duration in a table, and past serious illnesses, injuries, and operations are recorded in a procedure/illness table with the year.\"},{\"question\":\"What insurance and authorization statements are included?\",\"answer\":\"The form states it files primary and secondary insurance only, confirms coverage, explains financial responsibility for changes, authorizes release of information to secure benefits payment, and allows use of the signature on insurance submissions. It also specifies that co-pays, co-insurance, and deductibles are due the day of service.\"}]","New Patient Health Information - Please Download/Print & Return Instructions | PDF",1791840348,6]