Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

Transcription

1 Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Occupation Retired Yes No Emergency Contact Name Relationship Phone Number Referring Doctor Last Visit Primary Care Doctor Last Visit Cardiologist Last Visit Other Doctor Last Visit Pharmacy Phone Location How did you hear about us Reason for todays visit Insurance Information: Primary Insurance Insured Name ID# Secondary Insurance Insured Name ID# Signature Date

2 CURRENT / RECENT SYMPTOMS Check all that apply YES YES YES Blurred Vision Shortness of Breath Bleeding / Clotting Disorder Change in Voice Chest pain DVT / Blood Clots Difficulty Swallowing Palpitations Chronic dry skin / Itching Dizziness / Vertigo Fatigue Unhealed Sores / Ulcers Double Vision Weight Gain Coldness in Feet / Toes Headaches Weight Loss Cramping in Legs Hearing Loss Sinus / Allergies Discoloration in Feet / Toes Lack / Loss of Balance Joint pain Pain in Legs Ringing in Ears Abdominal Pain Numbness in Feet / Toes Seizures Blood in Urine / Stool Swelling / Edema in Legs Tremors Painful Urination Tingling in Feet / Toes Anxiety Frequent Urination Depression Urinary retention Other : MEDICAL HISTORY Check all that apply Abdominal Aortic Aneurysm Glaucoma Psoriasis A fib Gout Rheumatoid Arthritis Allergies / Sinus Heart Attack Scleroderma Alzheimer s Disease High Blood Pressure Stroke Anemia High Cholesterol Seizures / Convulsions Arthritis Hyperglycemia (high sugar) Thyroid Disease Hypo Asthma Kidney Disease / Dialysis TIA Bleeding Disorder Low Blood Pressure Tuberculosis Cancer Liver Disease Ulcers Type: Carpal Tunnel Syndrome Lupus Varicose Veins Cataracts Lung Disease COPD Venous Insufficiency Congestive Heart Failure Migraines Other Coronary Heart Disease Dementia Detached Retina Diabetes Insulin Meds Diet Emphysema Epilepsy Fibromyalgia Mitral Valve Prolapse Multiple Sclerosis Neuropathy Osteoarthritis Osteoporosis / Osteopenia Pacemaker Parkinson s Disease Hyper

3 SURGICAL HISTORY Check all that apply and indicate year Abdominal Aortic Aneurysm Cardiac Angioplasty / Stent Other Angiogram Carotid Endarterectomy Angioplasty / Stent Carpal Tunnel Appendectomy Colon Back Fistula Bladder Gall Bladder Bowel Heart Bypass (CABG) Breast Joint Replacement Bypass Legs Prostate Allergies Medication Allergy Reaction Medications Medication Strength (mg) Frequency Social History Tobacco Never Rarely Daily Previous Packs per Day Length of Use Quit Alcohol Never Rarely Daily Previous Amount Length of Use Quit Illicit Drugs Never Rarely Daily Previous Type Length of Use Quit

4 Family History Living Deceased Health Issues Age Cause of Death Mother Father Sibling Sibling Children Children Spouse Other Release and Authorization I authorize the doctor and his staff to release any information including the diagnosis and records of treatment or examination to third party payers and/or other health care practitioners. I give consent for other health practitioners and medical facilities to release medical records to Arizona Vein and Vascular Center as it relates to my continuing care. I understand that this consent is good for one year from the date signed and maybe revoked at any time in writing. I authorize and request my insurance company to pay directly to Arizona Vein and Vascular Center and its affiliates any benefits covered by my insurance plan. I understand that my insurance may pay less than the actual bill for service. I agree that I am responsible for any charges for services rendered to myself or my dependent. [ ]Yes [ ]No I consent to have detailed messages and test results left on an answering machine, voice mail, or . Patient PRINT Signature Date Legal Representative (if applicable) Signature Date Arizona Vein & Vascular Center Phone Fax

5 Phone Fax HIPAA Privacy Rights Request Form PATIENT INFORMATION Name (Last, First, Middle Initial) Date Street Address City State Zip Code Primary Phone Number Other Phone Number Address Type of Request (circle what applies) Access/Copy Amendment Restriction Confidential Communication Accounting of Disclosures Complaint Please describe nature of action requested (type of information requested: nature of amendment, resctriction, alternative communication, or complaint, etc.) in detail. (Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below) Please list (Company Name) staff members that were contacted regarding this matter: Name Date Name Date Signature Date FOR ADMINISTRATIVE USE ONLY: Date received Action taken Date Action taken Date Privacy Official Signature Date (Attached additional documentation, if applicable)

6 Phone Fax AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient s Name: Date of Birth: Previous Name: Social Security #: I request and authorize to release healthcare information of the patient named above to: Name: Address: City: State: Zip Code: This request and authorization applies to: o Healthcare information relating to the following treatment, condition, or dates: o All healthcare information o Other Definition: Sexually Transmitted Disease (STD) as defined by law, RCW et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea. o Yes o No o Yes o No I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s)/provider/facility listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) /provider/facility listed above. Patient Signature: Date Signed: THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.