We request that you refrain from wearing perfumes or colognes, as we see many patients who are susceptible to allergic reactions to scents.

Transcription

1 Providence Medical Group-Hood River Internal Medicine 1108 June St. Appointment de Hood River, OR fax Appointment time Welcome to the Providence Medical Group-Hood River Internal Medicine. We welcome you as a pient and thank you for choosing us to participe in your health care. For your first appointment, please arrive 15 minutes prior to your scheduled appointment to complete registrion process. Additionally, we ask th you bring all medicions you are currently taking, including supplements and over-the-counter medicions, in the original bottles, so th they charted correctly upon your initial visit. Please request the last six months of chart notes from your current primary care physician and the last two years of specialty care including labs and X-rays. Please see the enclosed informion regarding your first appointment. We request th you refrain from wearing perfumes or colognes, as we see many pients who are susceptible to allergic reactions to scents. Please bring the following to your appointment: Photo ID Medical insurance card Completed enclosed forms All current medicions, in the original bottles If you have any questions, please call us We look forward to seeing you soon. Providers: Ryan Peterson, M.D., Jodi Ready, M.D., Gary Regalbuto, M.D., Stephen Vogt, M.D.

2 Providence Medical Group-Hood River 1108 June St. Hood River, OR fax History form: Please fill out your medical history as completely as possible. Medicions: Please bring in all your current medicions in the original bottles. Record release form: If you are transferring from another care provider, please request your records be transferred to your new doctor before to your appointment. You will find this form, Authorizion for Release of Medical Records, in your packet. If you need a copy of your lab results, you can sign a two-year release of records in your physician s office. Cancellion policy: We ask th you contact our office least 24 hours before to your scheduled appointment if you need to cancel or reschedule. This allows appointments for other pients. Before your appointments: Please arrive 15 minutes before your appointment to allow time for registrion. Remember to transfer your medical records from your previous provider. Notice: If you arrive more than 10 minutes past your scheduled appointment time, you may be asked to reschedule your appointment. Billing Questions: or

3 Initial Health Questionnaire Pient Name DO YOU HAVE RECENT OR RECURRENT PROBLEMS WITH: Age Sex M F De of Birth / / Marital Stus M S W Div Sep HEADACHE SWELLING OF YOUR LEGS FAINTING SPELLS HIGH CHOLESTEROL EXCESSIVE DIZZINESS LEG CRAMPS WITH WALKING NUMBNESS OR TINGLING IN HANDS OR FEET LEG CRAMPS AT NIGHT MOMENTARY LOSS OF VISION IN ONE EYE ABDOMINAL PAIN OR CRAMPING DOUBLE VISION HEARTBURN DECREASING MEMORY NAUSEA OR VOMITING WEAKNESS SPECIFICALLY ON ONE SIDE OF BLACK COLORED STOOL YOUR BODY RECTAL BLEEDING SLURRED SPEECH DIARRHEA HEAD TRAUMA CONSTIPATION TREMOR OR HAND SHAKING CHANGE IN SIZE OR SHAPE OF STOOL DEPRESSION PAIN OR BURNING ON URINATION FREQUENT FALLS DIFFICULTY STARTING URINATION RINGING IN EARS DO YOU GET UP AT NIGHT TO URINATE DECREASE IN HEARING HOW MANY TIMES? RECURRENT NOSEBLEEDS ANY PENILE DISCHARGE SINUS TROUBLE BLOOD IN URINE PERSISTENT HOARSNESS LOSE URINE WITH COUGHING OR SNEEZING DIFFICULTY OR PAIN ON SWALLOWING LOSE URINE AT OTHER TIMES RECURRENT MOUTH SORES DECREASE IN THE FORCE OF URINE STREAM EXCESSIVE BLEEDING W/BRUSHING FREQUENT URINARY TRACT INFECTIONS PERSISTENTLY ENLARGED GLANDS BACK PAIN CHEST PAIN JOINT PAINS COUGH UP BLOOD HEAT OR REDNESS OF ANY JOINT PAIN IN ARMS ARTHRITIS SOAKING NIGHT SWEATS WHAT DID YOU WEIGH 1 YEAR AGO? CHRONIC OR FREQUENT COUGH WHAT DID YOU WEIGH 5 YEARS AGO? WAKE UP NIGHTS SHORT OF BREATH EXCESSIVE FATIGUE WITHOUT REASON HOW MANY PILLOWS DO YOU USE? BRUISE EASILY WITHOUT HITTING SHORTNESS OF BREATH ON: INTOLERANCE TO HOT WEATHER WALKING SEVERAL BLOCKS INTOLERANCE TO COLD WEATHER ONE FLIGHT OF STAIRS CHANGE IN HAIR TEXTURE ON LYING DOWN LOSS OF HAIR PALPITATIONS OR FLUTTERING OF HEART IMPOTENCE ARE YOU EXPERIENCING PAIN RIGHT NOW? HOW LONG HAVE YOU BEEN EXPERIENCING 6 months or less IF SO, PLEASE RATE ON A SCALE OF 1 TO 10 (1 BEING THE LOWEST, 10 THE HIGHEST) THIS PAIN? More than 6 months Do you have a rubber (lex) allergy? would you describe your health? EXCELLENT GOOD FAIR POOR

4 NAME: DOB: PLEASE LIST ALL CONDITIONS THAT YOU SEE A PHYSICIAN FOR AND PHYSICIAN IN CHARGE YEAR OF ONSET ATTENDING PHYSICIAN PLEASE LIST ALL OPERATIONS WITH YEAR PERFORMED AND SURGEON PLEASE LIST ALL MEDICATIONS, DOSES AND HOW OFTEN YOU TAKE THEM, INCLUDING HERBAL & NATUROPATHIC MEDICATIONS: PLEASE LIST ALL MEDICATION ALLERGIES AND THEIR REACTIONS Do you or have you ever used Tobacco? Do you use Alcohol? Do you use Caffeine? Do you use injectable Drugs? FAMILY HISTORY IF LIVING IF DECEASED AGE HEALTH AGE AT DEATH CAUSE FATHER MOTHER NUMBER OF BROTHERS NUMBER LIVING NUMBER DECEASED CAUSE NUMBER OF SISTERS NUMBER LIVING NUMBER DECEASED CAUSE NUMBER OF CHILDREN NUMBER LIVING NUMBER DECEASED AGES OF EACH ILLNESSES OF CHILDREN Do you know of any blood relive who has or had (check and give relionship) CANCER Heart Disease High Blood Pressure DIABETES STROKE High Cholesterol

5 Others Involved in Your Health Care This office requires a signed release to give any informion regarding appointments, test results, health stus, etc. to others. Anyone not listed on this form will not be given any informion without a separe, specific release signed by the pient or legal representive. Please note: Pients are no longer considered minors after age 17. If a pient over the age of 17 wishes to release informion to a parent or guardian, they must include the name and relionship of th person on this form. Informion will not automically be given because a pient resides with his or her parent(s) or guardian(s). Medical informion is to be released to: Name Relionship Phone number Pient name [Print] Authorized signure Legal representive if not pient [Print] De of birth Today s de Relionship MR#

6 Authorizion for Release of Medical Records Pient s Name: First Middle Last De of Birth: / / Social Security Number: PERMISSION IS HEREBY GRANTED FOR RELEASE OF INFORMATION FROM: TO: Name (Medical Provider holding records): Address: Name: Phone # Address: Fax # The purpose of the release is: Diagnostic Evaluion Reimbursement Follow-Up Care Legal Other The following informion may be released: Clinical notes (Re: ) Laborory Reports ( LAST 2 YEARS) Immunizion Records Medicion Records X-Ray Reports Other: EKG S, PATHOLOGY REPORTS, SPECIAL STUDIES, SPECIALISTS CONSULTS, HOSPITAL RECORDS INCLUDING ER VISITS, ADMITS, H&P S, IN PT. CONSULTS, SURGERY/PROCEDURE REPORTS, AND DISCHARGE SUMMARIES (LAST six MONTHS ONLY) Informion may be released for des of service from SEE ABOVE through SEE ABOVE This authorizion expires six months from the de signed or: (specified expirion de) I have read the above and fully understand its contents. I have asked questions about anything th was not clear to me and I am sisfied with the answers I have received. (Signure of pient or representive) Relionship (if signed by representive) De Signed Witness (optional) Driver s License/Identificion I do /do not specifically consent to transmission of my medical records via a facsimile (fax) machine. I recognize th the informion disclosed may contain drug/alcohol informion th is protected by Federal and Ste law. I specifically consent to disclosure of such informion Signure De Signure De I recognize th the informion disclosed may contain mental health informion th is protected by Federal and Ste Law. I specifically consent to disclosure of such informion I recognize th the informion disclosed may contain informion regarding sexually transmitted diseases or HIV / AIDS testing informion. I specifically consent to disclosure of such informion Signure De Signure De This authorizion may be revoked any time unless prior action has been taken as a result of this form. Records obtained as authorized by this consent for informion release will be maintained in accordance with Federal confidentiality regulions (Title 42 of the Federal Register) which prohibits re-disclosure. Medical Record #