Joseph Bryer, M.D.
Joseph Bryer, M.D.

New Patient Information                                           Joseph Bryer, M.D.  

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Name__________________________________________________________             Date:_______________

Address:_____________________________________________________________

City:________________________State:______Zip:_____________

Home Phone:________________ Work/Cell Phone:_________________If necessary, may we call you at work? Yes___ No___ 

Age: ______ Marital Status: _____ Number of Children:_______

Social Security Number:______________________ Birthdate:_________________ Occupation__________________________     

Primary Insurance Carrier_____________________________     Policy Number___________________________

                  Subscriber(if different from patient):____________________________Group #__________

Secondary Insurance Carrier___________________________     Policy Number__________________________

                  Subscriber(if different from patient):____________________________ Group #__________

Medical History:

Which of the following medical conditions do you have now or have you had in the past:    O High blood pressure

O Diabetes      O Heart attack/angina       O Stroke       O Asthma       O Thyroid gland disease       O Head injury with loss of consciousness       O Seizures or epilepsy         O Stomach ulcer      O Cancer (specify type)       O Liver disease                      O Kidney disease       O Multiple sclerosis        O Glaucoma       O Parkinson’s disease        O Irritable bowel syndrome          O Ulcerative colitis/Crohn’s        O Emphysema      O Other significant medical conditions?: Notes:_______________________________________________________________________________________

Allergic to any medications?:       O No      O Yes,  Specify : ____________________________________________________

Have you ever been under the care of a psychiatrist?       O No      OYes

Have you ever been admitted to a psychiatric hospital?   O No        OYes

Have you ever done anything to intentionally harm yourself?     ONo       OYes

Have you ever done anything to cause physical harm to others?     O  No       OYes

Primary Medical Doctor:______________________________     Referred to me by whom?:____________________________

Current Medications:______________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

Emergency Contact (Name and Phone Number):______________________________________________________________

Any Additional Comments/Information?:______________________________________________________________________

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Copyright, Joseph Bryer, M.D. 2006-2017