Ernest Gesiotto, MD
Francesca Gesiotto, DO
Nicholas Byers, MD

6311 South Pointe Blvd.
Fort Myers, Florida  
33919 
(239) 275-0040  

DATE:_____/______/_____	      NEW PATIENT REGISTRATION FORM

Name (please print last, first, middle initial)			          date of birth
		
Social security number							 Male    Female
__________-___________-_____________	
Street address					                        	   city, state, ZIP Code
	
Northern Street address (if applicable)				               city, state, ZIP Code
	
Preferred Phone Number					Additional phone number
(__________)__________-_________________	(__________)__________-_________________	
Email address                     	    Married   Sig other   Single   Widowed   Divorced
	
Emergency contact	  	   Relation 		             Telephone number
		(________)__________-__________	
Insurance Information
Primary	Secondary 	
Name:	Name:	
Address: 	Address:	
Policy #:	Policy #:	
Pharmacy Information
Preferred Pharmacy	Secondary Pharmacy	
Name:	Name:	
Address: 	Address:	
Phone:	Phone:	
Fax:	Fax:	
Please list your      Current prescription medications
Medication	Dosage	Directions	

			

			

			

			

			

Please list your      Current supplements/herbal/over the counter 
Medication	Dosage	Directions	

			

Please list any 		 Medication/Substance Allergies:           
•	NONE	       or
Medication/Substance	Reaction	

		

Please list 	Major hospitalizations/surgeries:		
Year	Description	

		

Please list your Medical problems, current and past:
Date	Problem	

		

		

Please check your if you have ever had the following:
	Anemia		Dementia		Kidney Problems	
	Anxiety		Depression		Liver Disease	
	Arthritis		Diabetes		Osteoporosis	
	A Fib		GERD		Prostate Problems	
	Asthma		Gout		Seizures	
	Blood Clots		Heart Problems		Stroke/TIA	
	Cancer		Hypertension		Ulcers	
	COVID		High Cholesterol 		Thyroid Disease	

Please list Family Medical problems:
Relative	Medical Problems	Cause of death, if applicable	
Father			
Mother			
Brother 			
Sister			
Son			
Daughter			
Other:			

Please list	 Other doctors you are seeing:
Name	Specialty 	City, State	Last Visit	

				

Health Maintenance: Please fill in the date of any of the following exams/tests: 
Exam/Test	Date	Exam/Test	Date	
Shingles/Zostavax Vaccine		DEXA/Bone Density		
Influenza Vaccine		Colonoscopy		
Pneumonia Vaccine		PAPSmear		
Tdap (tetanus)		Mammogram		
Hepatitis B Vaccine		Date of last menstrual period		
Hepatitis C Vaccine		PSA		
COVID 19 Vaccine		Prostate Screening		
Chest X-ray		EKG		

Last blood test
Date	Location	

Social History/ Wellness/ Prevention 
Occupation/Employer: 	
Do you have any children?  No     Yes      How Many? _____ Males _____ Females	
Current Tobacco Use:  No     Yes, for _____ years  Previous use, year quit ___ #Packs per week     
 Chewing     Cigar     Pipe     Cigarette     Vapor	
How many alcohol beverages do you consume per week? ___________   Type? ________	
Do you drink caffeine?    No     Yes      Average beverages per week?_______     	
Are you sexually active?     No     Yes      	
Do you drive?    No     Yes      	
Do you have a living will?  No     Yes        If yes, please provide a copy	
Do you have a power of attorney?  No     Yes      If yes, please provide a copy	
Do you use any assistive devices?  No     Yes      If yes, please provide details ________________ ______________________________________________________________________________________	
Who lives with you?	
Do you have an alert system?  No     Yes      	
Do you have trouble hearing?  No     Yes      If yes, do you wear hearing aids?  No     Yes      	
Do you exercise regularly?  No     Yes      If yes, how often?__________________________________
Type of exercise?___________________________________________________________________________	
Do you sleep well at night?  No     Yes      	
Additional concerns to share with the doctor: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________