Skip to the content
Spring Hill Primary Care
(352) 835-7155
(352) 835-7199
10500 Spring Hill Dr, Spring Hill, FL 34608
SPRING HILL PRIMARY CARE
Menu
HOME
OUR PRACTICE
OUR PHYSICIAN
SERVICES
Family Medicine
Primary Care
Internal Medicine
Annual Physicals
PATIENT PORTAL
PATIENT FORMS
MR Authorization
New Patient Packet
CONTACT
New Patient Packet
Fields marked with an asterisk (
*
) are required.
Name
*
Date
Registration Form
Today's Date
Patient First Name
*
Middle Name
Patient Last Name
*
SR / JR / Other
Preferred Name (if different)
Sex
Male
Female
Date of Birth
*
Social Security Number
Address
*
Insurance
*
Member ID#
*
Home Phone
*
Cell Phone
Work Phone
Email Address
*
Marital Status
*
Married
Single
Separated
Divorced
Widow
Medical Information
Who was your previous medical doctor?
*
Doctor Address
Doctor Phone
*
Emergency Contact
Name
*
Relationship
Address
Phone Number
*
Medical History
Please tick this box if it does not apply.
Allergies
Reaction
Current Medications
Please tick this box if it does not apply.
Name
Dose
Start
End
Prescribed By
Preventive Care
Please tick this box if it does not apply.
Procedure
Year
Where
Physician
Eye Exam
Labs
Colonoscopy
Mammogram
Gynecological Exam
Pap Smear
Last Menstrual Cycle
Pregnancies
Births
Miscarriages
Bone Density
Prostate Exam
Prostate Specific Antigen (PSA)
Do you have a living will?
Yes
No
Do you have a DNR or file?
Yes
No
Vaccinations
Please tick this box if it does not apply.
Vaccine
Date
Tetanus
Influenza Vaccine
Zostavax
Shingles
Meningitis
Yellow Fever
Polio
Pneumonia Vaccine
Hep A
Hep B
COVID19 Vaccine
Family History
*
Relation
Details
Mother
Father
Smoking
Do you smoke?
Yes
No
Years Smoking
Packs per Day
Alcohol Use
Yes
No
Type
Beer
Wine
Liquor
Drinks per Week
Recreational Drugs
Yes
No
Needle Use
Yes
No
Sexual Activity
Yes
No
Number of Partners
Partner Gender
Male
Female
Birth Control
None
Condom
Pill/Patch/IUD
Vasectomy
Tubal
Exercise
Yes
No
Exercise Type
Duration
Sleep
Hours per Night
Sleep Problems
Yes
No
Specialists
Specialist
Name
Last Visit
Cardiology
Dermatology
Other 1
Other 2
Preventive Care – Functional Assessment
Question
Response
Details
Have you had any falls in the past year?
Yes
No
How many falls?
Do you have any fractures due to a fall?
Yes
No
Where are they located?
If you are having pain at this time, what is your pain scale?
1–10
Where is the pain?
Do you use medical equipment supplies at home?
What type of equipment?
Do you have a medical living will?
Yes
No
Do you have a power of attorney?
Yes
No
Who is your power of attorney?
Do you have a hearing problem?
Yes
No
Which ear?
Left
Right
Both
Do you need help with any of the following?
Activity
Yes / No
Meal Preparation
Yes
No
Doing Housework
Yes
No
Dressing Yourself
Yes
No
Bathing Yourself
Yes
No
Eating
Yes
No
Walking
Yes
No
Transportation
Yes
No
Surgeries & Medical History
Have you had any surgeries?
Medical History
Agreements
Full Name
Signature (Type Name)
*
Date
Current Medical Conditions
1.
2.
3.
4.
5.
Please List Below If You Have Any Other Medical Conditions.
Any Questions Or Concerns For Dr. Kolli?
What Pharmacy Would You Like To Use For Prescriptions?
(Can be changed at any time)
Name:
Street Address:
City / State / Zip:
Phone Number: