Mirana

[Mirana]

RAVENBLACK MEMORIAL HOSPITAL
PATIENT INFORMATION FORM

NAME: Mirana A. Garcia
ADDRESS: 23 Ruby St., Apt 604
SOCIAL SECURITY NUMBER: [censored]
DOB: 11/26/1990 SEX: F MARITAL STATUS: S RACE: Hispanic
LANGUAGE PREFERENCE: English, Spanish
HEARING IMPAIRED?: N VISION IMPAIRED?: N
PATIENT'S EMPLOYER: Erato County Fire & EMS
HOW DID YOU HEAR ABOUT US? Walk-in
PRIMARY INSURANCE INFORMATION
[censored]
DO YOU ENGANGE IN ANY OF THE FOLLOWING?
SMOKE: N DRINK: Y DRUGS: N

MEDICAL HISTORY
Have you EVER HAD, or do you have, any of the following? Check EACH item that applies.
High blood pressure
Shoulder/elbow/wrist/hand pain
Broken bones
Bone or joint problems
Back pain/injury
Knee pain/injury
Severe headaches
Depression or anxiety
Emotional or psychiatric problems

WHAT IS YOUR CURRENT COMPLAINT?
Loss of appetite, increased thirst, sunlight sensitivity, fever, migraine

THANK YOU FOR YOUR INFORMATION. PLEASE RETURN THIS FORM TO A RECEPTIONIST.