Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Transcription

1 Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please bring a list of current medications, including prescribed and non-prescribed, over-the-counter medications, and any herbal supplements you may take. We also need any medical records pertinent to your visit. If you have diabetes, please bring your glucose meter and the last 2 weeks of your blood sugar logs with you to your appointment. Your co-pay is required to be paid at the time of service. If you do not have insurance, a minimum deposit of $96 is required at the first visit. If your insurance carrier requires prior authorization and/ or a primary care referral, you are responsible for obtaining these prior to your visit. Please confirm that we are an in-network provider with your insurance carrier. Should you need to cancel or reschedule your appointment, please call We request at least 48 hours' advanced notice when cancelling to allow us time to offer the appointment to another patient who may be waiting for treatment. If you cancel with less than 48 hours' notice, we may be unable to schedule future appointments for you in our clinic. We look forward to seeing you. We now offer convenient appointment reminders via text message! If you would like to sign up for this service, make sure we have your cell phone number on file and find more details from us at your office visit. We look forward to seeing you.

2 PATIENT REGISTRATION Patient Name (Last, First, MI) Address City State Zip Home Phone Work Phone Cell Phone address SS# Date of Birth Sex: Female Male Marital Status Spouse/partner name (if any) Employer Name Phone Employer Address City State Zip Referring Physician Name Phone PCP Name Phone Emergency Contact Phone Which is preferred phone number to call? Home Work Cell. Is it okay to leave voice mail messages with private health information? Yes No Please list any family members with whom we can discuss your medical care: None List: INSURANCE INFORMATION Primary Insurance Insurance Name Policy # Phone Name of Insured Relationship SS# Date of Birth Employer Name Phone Employer Address City State Zip Secondary Insurance Insurance Name Policy # Phone Name of Insured Relationship SS# Date of Birth

3 PATIENT HEALTH QUESTIONNAIRE Patient Name Date of Birth Referring Physician REVIEW OF SYSTEMS Please circle if you have recently had any of the following: General: Skin: HEENT: Neck: Respiratory: Breast: Cardiovascular: Gastrointestional: Female genitourinary: Musculoskeletal: Neurological: Psychiatric: Endocrine: Hematology: Fatigue, Fever, Night Sweats, Weight gain, Weight loss Hair loss, Rash, Skin color changes Blurred vision, Double vision, Eye pain, Decreased hearing, Ear discharge, Ringing in the ears, Runny nose, Frequent colds, Nasal congestion, Hoarseness, Sore throat, Decreased sense of smell Neck mass, Neck stiffness, Neck swelling Cough, Sputum production, Wheezing Nipple discharge, Skin changes Abnormal blood pressure, Chest pain, Palpitations, Shortness of breath, Swelling of extremities Abdominal pain, Abdominal swelling, Black tarry stool, Constipation, Diarrhea, Excessive gas, Hemorrhoids, Heartburn, Jaundice, Laxative use, Nausea, Painful swallowing Excessive menstrual bleeding, Menstrual irregularities, Painful urination, Vaginal dryness, Excessive urination at night Back pain, Joint pain, Joint stiffness, Joint swelling, Leg cramps, Muscle weakness Decreased memory, Fainting, Headaches, Numbness, Paresthesia, Seizures, Syncope, Tremor, Tingling Anxiety, Depression, Memory loss, Mood changes Cold intolerance, Excessive sweating, Excessive thirst, Excessive urination, Heat intolerance, Hot flashes, Libido change Anemia, Blood clots, Easy bruising, Nose bleed

4 Patient Name Date of Birth DIABETES MEDICATIONS oyes ono Insulin oyes ono If yes, please write insulin type, how much you take every day and how many times you take it below. If you use a sliding scale please write the scale as well and which insulin you use for the scale. If you use an insulin pump please write the pump type, insulin you use and the pump settings below. Oral Medications for Diabetes? oyes ono. If yes, list the medication name(s), dose strength and frequency below. Your eye doctor (Ophthalmologist) Your foot doctor (Podiatrist) PATIENT MEDICATIONS (All other except diabetes meds) List all prescription and over the counter medications and supplements you take MEDICATION NAME (Example: Aspirin) DOSE STRENGTH (81mg) DOSE FREQUENCY (1 Tab once daily)

5 Patient Name Date of Birth PATIENT MEDICAL HISTORY Do you currently have or have had any of the following problems. DIAGNOSIS CHECK IF YES DIAGNOSIS CHECK IF YES Diabetes Liver problems High Blood Pressure Stomach ulcer Cholesterol Problems Heartburn Heart Disease Anxiety Kidney Failure Depression Overactive Thyroid Panic attacks Underactive Thyroid Arthritis Stroke Thyroid cancer Seizures Prostate cancer Osteoporosis Breast cancer Fractures Vascular problems PATIENT SURGICAL HISTORY List all surgeries you have had and year occurred. Please be as accurate as possible. SURGERY (For Example: Gall bladder removal) YEAR (1992) SOCIAL HISTORY Marital Status Number of children with ages Occupation (If retired list previous occupation) Tobacco: ocigarette ocigar ochewing tobacco oother (Specify) Quantity per day Years Used Year Quit Alcohol: Type (Example: Beer, Wine) Quantity per week Years Used Year Quit Recreational Drugs: Type Years Used Year Quit Exercise: Type Amount per Week

6 Patient Name Date of Birth FAMILY HISTORY Indicate if your family members have any of the following DIAGNOSIS CHECK IF YES WHICH FAMILY MEMBER(S) HAVE IT? Diabetes High Blood Pressure Cholesterol Problems Heart Disease Kidney Failure Overactive Thyroid Underactive Thyroid Thyroid Cancer Breast Cancer Prostate Cancer Osteoporosis Stroke MEDICATION ALLERGIES Please list medications you are allergic to and the reaction you have to each one of them. MEDICATION ALLERGIC REACTION PHARMACY Name Address Phone number FOR WOMEN ONLY - How old were you when you had your first period? - Are your cycles regular? oyes ono - When was your last period? - When did you undergo menopause? - How many pregnancies have you had?