Accepting New Patients

(770) 282-3998
Appointments available Monday - Thursday 8am to 5:30pm

Kroll Care PC

290 Heritage Walk

Suite 102

Woodstock Ga 30188

PATIENT REGISTRATION FORM


PATIENT INFORMATION


INSURANCE INFORMATION

PRIMARY INSURANCE

Self Spouse Parent Other

SECONDARY INSURANCE

Self Spouse Parent Other
The above information is true to the best of my knowledge. I authorize insurance benefits to be paid directly to Kroll Care PC. I understand I am financially responsible for any balance. I also authorize Kroll Care PC to release any information required to process my claims.

Kroll Care PC

290 Heritage Walk

Suite 102

Woodstock Ga 30188

New Patient Medical History - Please fill this form prior to your first appointment


Past Medical History

Condition/Disease

Year Began

Hypertension
High Cholesterol
Hypothyrodism(low thyroid)
COPD, Emphysema or asthama
Diabetes
GERD
Depression or Anxiety
Heart Problems

Past Surgical Procedures / Hospitalization / Serious Injuries or Fractures

Operation / Hospitalization / Injuries

Month / Year

No Yes

Medication or Food Allergies or Intolerances

List below medications or foods causing an allergic reaction(i.e., rash, swalling) or intolerance(i.e., nausea)

Medication / Food

Reaction


Medication, Vitamins and Herbal Supplements

Medication

Strength

Number of pills taken and frequency


Social, Educational and Work History


Employed Unemployed Retired Disabled
No Yes
No Yes

No Yes

Men Women Both
No Yes
No Yes
*** You must inform Kroll Care PC if you are pregnant before taking narcotics ***

Family Health History

Please list below the health history of your blood (genetic) first degree relatives

Relative

Living or Deceased

Current age or age at death

Cause of Death

Health Problems

Father:
Mother:
Brother:
Sister:

Review of systems

Please review the following symptoms and select those items that are a problem for you
Vision problems
Hearing problems
Sinus trouble
Hay fever
Nosebleeds
Sore throat
Hoarseness
Lumps in neck
Tooth problems
Cough
Coughing blood
Excessive hunger
Excessive thirst
Weakness
Wheezing
Asthma/COPD
Emphysema
Broanchitis
TB exposure
Chest pain
Chest discomform
Shortness of breath
High blood pressure
Diabetes
High cholesterol
Fatigue
Fever/Sweating
Fainting
Lumps in breast
Breast discharge
Trouble swallowing
Nausea
Vomiting
Abdominal pain
Hepatitis/Jaundice
Gallstones
Diarrhea
Constipation
Blood in stool
Seizures/Tremor
Headaches
Numbness/tingling
Frequent Urination
Incontinence
Blood in urine
History of STD's
Anemia
Easy bruising
Pain in legs
Joint pain/stiffness
Blood clot
Weight loss/gain
Heat/cold intolerance
Anxiety/Depression
Difficulty sleeping
None of the above

New Appointment / Consultation Request

Leave this empty:


Appointments Monday - Friday: 8am - 6pm

Prefer to make a phone call?

New Patients

(770) 282-3998

Existing Patients

(678) 273-3456