Dear Patient: We look forward to seeing you! Please call us at (423) should you have any questions.
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1 Dear Patient: Thank you for choosing The Chattanooga Heart Institute for your cardiac care. With 25 board-certified cardiologists, two cardiothoracic surgeons and seven advanced practice providers, we offer a comprehensive, team approach to your care. Please fill out the attached forms and bring them with you to your appointment or mail them prior to your appointment. In order for us to provide you with the best care possible, it s important that you fill out all forms completely. Please arrive 30 minutes prior to your first appointment. For future appointments, we ask that you arrive 20 minutes before your appointment. If you re late for an appointment, you may not be seen. If an appointment is available at a later time that day, you ll have the option of seeing the physician at that time. This is in consideration of the needs of all of our patients. It s important that you bring all medications in their original bottles or that you bring a detailed list with the name of the medication, the dosage and when you take each medication. Please also bring a list of any over-the-counter medications you take such as vitamin supplements, aspirin, etc. During your visits, please let the nurses know if you need a refill of a prescription. Bring your insurance card and a photo ID to each appointment. To protect your privacy, each time you call our office, you ll be asked your date of birth and the last four digits of your social security number. If someone calls on your behalf, please provide them with this information. This is to ensure that we are speaking only to someone whom you ve asked to call on your behalf. We look forward to seeing you! Please call us at (423) should you have any questions. Physicians and staff The Chattanooga Heart Institute Rev. 5/2018 Main Office: 2501 Citico Ave. Chattanooga, TN WEL_LET_PT-E
2 NEW PATIENT FORM MR#: Date: Name: Marital Status: (Last) (First) Married Divorced Single Widowed Age: Date of Birth: Referring Physician: Occupation: (First) (Last) (if applicable) Primary Care Physician: Employer: (First) (Last) What type of problem led to your visit here today? When did this start? Quick Review of Systems: Are you currently experiencing any of the following symptoms? (please circle all that apply) Chest pain Heart fluttering or racing/palpitations Excessive sweating/diaphoresis Passing out or fainting/syncope Difficulty breathing lying down/orthopnea Shortness of breath that wakes you up/pnd Pain in legs when walking/claudication Ankle or leg swelling/edema Weight gain Weight loss Fever Visual changes Hearing loss Snoring Coughing up blood/hemoptysis Shortness of breath/dyspnea Feeling of sickness to the stomach/nausea Heartburn/reflux Bleeding Blood in urine/hematuria Waking up at night to urinate/nocturia Dizziness Memory loss Seizures Depression Hallucinations Low blood count/anemia Low blood platelet count/thrombocytopenia Thyroid enlarged/goiter Tremors Rash Skin sores Joint pain Muscle cramps/pain/myalgia Anemia Blood Clots Cardiac Arrhythmia Cardiovascular Disease Carotid Artery Stenosis COPD Angioplasty CABG/Heart Bypass Cardiac Pacemaker Past Medical History: (please circle all that apply) Coronary Artery Disease Diabetes Elevated Cholesterol Hypertension Myocardial Infarction Renal Disease Past Surgical History: (please circle all that apply) Dialysis ICD/Defibrillator Insertion Other: Aneurysm Heart Valve Disease Congestive Heart Failure Stroke TIA Other: EP Study/Ablation Arteriogram/Heart Cath/Stent Vascular Surgery Heart Valve Surgery Date: Provider Signature:
3 Patient Name: MR #: Date: Diagnostic Studies: (please circle all that apply) Echocardiogram Treadmill Test Holter Monitor CT/CTA Nuclear Stress Test EP Study Vascular Ultrasound Family History: (please circle all that apply) 1. If your relative listed below had the condition, please enter their age when it started in the box. 2. If you don t know how old they were when it began, just place a check mark in the box. 3. Enter your relatives current age or age at death in the last column. Abnormal Heart Rhythm Heart Failure Heart Attack or Surgery Sudden Death High Cholesterol High Blood Pressure Diabetes Current Age Cause of death Age at Death Father Mother Brother #1 Brother #2 Brother #3 Sister #1 Sister #2 Sister #3 Social History: Do you smoke? No/Never Yes or Former Age started: Daily Use # per day? Age stopped: (if applicable) Cigarette Cigarillo Cigar Pipe Smokeless Snuff Vapor/Electric Do you drink alcohol? No Yes Type: How often: Amount: Last drink: Do you consume caffeine? No If yes, how much do you consume per day? Yes Coffee Soda Energy drink Chocolate Do you exercise? No Type of exercise: Yes Hours per week: Allergies: Contrast Dye Latex Allergy No Known Allergies Any medication allergies: Date: Provider Signature:
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6 Consent to obtain information on prescription medication Name (print) Date of birth MR # In order to help ensure that my medications are managed safely and accurately, I consent to The Chattanooga Heart Institute clinical staff electronically procuring from Sure Scripts information on the prescription medications I ve had filled at all pharmacies and mail-order pharmacies within the last 12 months. Signature Date Rev CON_OB_IN_RX E
7 In order to provide all patients with the best possible care, it is necessary to have policies in place regarding arriving late for appointments, failure to keep appointments and for short-notice cancellations. Those patients that don t keep appointments delay the delivery of care to other patients. We appreciate your cooperation in striving to arrive on time for each appointment and in keeping all scheduled appointments. Late Policy We ask that if you are going to be a few minutes late for an appointment that you please call and let us know that you are on your way. If you arrive more than 15 minutes late, it may be necessary for us to reschedule your appointment for another day. Cancellation of Appointments and No-Show Policy Patients who need to cancel or reschedule an appointment are asked to call the office and give a minimum of a 24 hour notice. This will allow that appointment time to be filled by other patients awaiting care. It is a violation of our policy to allow repeated cancellation of appointments without the required notice. Patients who fail to show for a scheduled appointment without 24-hour notice will be charged a $50.00 no-show fee. If a 3 rd no-show occurs, this may result in a discharge from our practice. Should you incur a no-show charge, it will be billed to your account and is your responsibility to pay as it is not payable by insurance. Informed Consent/Agreement (Please initial the following to indicate your understanding) I have been informed of and understand the Late Policy. I have been informed of and understand the Cancellation of Appointment(s) and No-Show Policy. I understand that a No-Show will result in a fee of $50.00 and that this fee is my responsibility and not covered by insurance. Printed name of patient Signature of Patient/Guardian Date (for office use only) MRN#
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Admission Form. Dr. Na Zhai Clinic 1200 S. 5th Street Springfield, IL Please call for help:
Admission Form Dr. Na Zhai Clinic 1200 S. 5th Street Springfield, IL 62703 Please call for help: 217-528-3199 Your privacy is important to us. The following form is intended to reduce the amount of paperwork
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
Welcome to the Center for Surgical and Medical Weight Loss
Welcome to the Center for Surgical and Medical Weight Loss Thank you for choosing Saint Thomas for your weight loss journey. Please take the time to read this information carefully. My appointment is scheduled,
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
EYE ASSOCIATES OF MONMOUTH, LLC
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PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring