Patient Forms. Is this work related? O Yes O No. Date: / / Patient/Guarantor s Signature: Patient Information. Patient under 18?
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1 Patient Forms Seeing Doctor: Date: / / How did you hear about us? O Male O Female Who is your Primary Care Dr? Patient Information Patient Name Date of Birth / / Nickname Marital Status: Address City State Zip Language Race Ethnicity Social Security # (Primary) Phone: O Home O Work O Other (Secondary) Phone: O Home O Work O Other May we leave a voic with medical information? O Yes O No Patient under 18? O Yes O No Address (If yes, please fill out all that is below) Guarantor's Name: Employer Phone Number: Employer Phone # Policy Holder Information O Same as Patient Name Date of Birth / / SS/ID # Relationship to paitent Address (if Different from Patient) Primary Insurance (who is the policy holder?) O Patient O Guarantor O Other Insurance Company ID# Group # Is this work related? O Yes O No Policy Id# Claims Mailing Address Adjuster's Name Adjuster's Phone Secondary Insurance (who is the policy holder?) O Patient O Guarantor O Other Insurance Company ID# Group # I understand that I am responsible for all charges regardless of insurance coverage. I agree to pay what I owe to this office upon request. If my account is referred to a collection agency, I agree to pay collection expenses including attorney's fees. My health insurance or other benefits relating to my medical condition are available to cover the cost for treatment provided by this office. I hereby assign those benefits to this office to be applied to my bill. A copy of this authorization shall be valid until rescinded in writing or replaced by one at later date. Date: / / Patient/Guarantor s Signature: Page 1
2 Name DOB Date Medications: O YES (List Medications & over the counter supplements below) OR O NO (I do not take medications) Name Of Medicine Dosage & How often taken Reason for taking medication. Allergies : O YES (List Below) O NO Allergies Reaction Surgical History: (Please list surgeries, hospitalizations) O None Dates Doctors: Please list all doctors currently involved in your care. Name Phone # Reason Page 2
3 Family Medical History Paternal Paternal Maternal Maternal Mother Father Siblings Grandmother Grandfather Grandmother Grandfather High Blood Pressure Lung Disease Bleeding Problems Diabetes Stroke Heart Disease Cancer (Specify what type) Other Family Members: Personal Social History Tobacco Use O Never O Quit/When O Current Smoker/Packs Per Day: Alcohol Use O Never O Rarely O Moderate O Daily How Much? Drug Use Occupation O Never Type/Frequency Anemia? O Yes O No Depression? O Yes O No Kidney Stones? O Yes O No Anxiety? O Yes O No Gout? O Yes O No Pancreatitis? O Yes O No Arthritis? O Yes O No Heart Disease? O Yes O No Panic Attacks? O Yes O No Asthma? O Yes O No Heart Mummur? O Yes O No Rashes? O Yes O No Bladder Infection? O Yes O No High Blood Pressure? O Yes O No Rheumatic Fever? O Yes O No Bleeding Problems? O Yes O No Hepatitis? O Yes O No Seizures? O Yes O No Blood Transfusion? O Yes O No High Cholesterol? O Yes O No Stroke? O Yes O No Cancer? O Yes O No Infections? O Yes O No TB? O Yes O No COPD? O Yes O No Inflammatory Bowel Disease? O Yes O No Thyroid Disease? O Yes O No Diabetes? O Yes O No Obesity? O Yes O No Ulcer? O Yes O No Other? O No O Yes (if yes explain) If Yes to cancer, What type? Past Medical History Page 3
4 General Review of Symptoms Endocrine Gastrointestinal Weight Gain O Yes O No Excessive thirst O Yes O No Nausea O Yes O No Weight Loss O Yes O No Thyroid disease O Yes O No Vomiting O Yes O No Fever O Yes O No Hormone problem O Yes O No Abdominal pain O Yes O No Fatigue O Yes O No Rectal bleeding O Yes O No Change in appetite O Yes O No Leg Cramps O Yes O No Bowel problems O Yes O No Night Sweats O Yes O No Muscle Aches O Yes O No Ophthalmologic Joint Stiffness O Yes O No Food allergy O Yes O No Blurred Double Vision O Yes O No Swollen Joints O Yes O No Other O Yes O No Glasses/Contacts O Yes O No Joint Pain O Yes O No Glaucoma O Yes O No Kidney Stones O Yes O No Insomnia Confusion/Memory loss O Yes O No Eye Disease/Injury O Yes O No Kidney Stones O Yes O No Confusion/Memory loss O Yes O No ENT Blood in urine O Yes O No Depression O Yes O No Ringing in the ears O Yes O No Testicle pain O Yes O No Breast (Including Men) Sore Throat O Yes O No Menstrual Problems O Yes O No Nipple Discharge O Yes O No Sinus Problems O Yes O No Breast Pain O Yes O No Decreased Hearing O Yes O No Tingling/Numbness O Yes O No Breast Lump O Yes O No Nose bleed O Yes O No Convuslions/Seizures O Yes O No Cardiovascular Neurologic Frequent headache O Yes O No Are you Pregnant O Yes O No Chest Pain at rest O Yes O No Paralysis/Tremor O Yes O No If so, How far along? Chest pain with exertion O Yes O No Loss of use of extremity O Yes O No O 1st Trimester O 2nd Trimester O 3rd Trimester Palpitations O Yes O No Number of pregnancies? Heart Trouble O Yes O No Bruise Easily O Yes O No O 0-2 O 3-5 O More than 5 Fluid accumulation in legs O Yes O No Slow to heal O Yes O No Number of Deliveries Respiratory Musculoskeletal Genitourinary Hematology Enlarged glands O Yes O No O 0-2 O 3-5 O More than 5 Shortness Of Breath O Yes O No Did you breast feed? Shortness of Breath with exertion O Yes O No Rash O Yes O No O Yes O No Wheezing/Asthma O Yes O No Itchy O Yes O No If Yes, Are you currently Breast Feeding? Coughing up blood O Yes O No Change in hair/nails O Yes O No O Yes O No Skin Allergy/Immunology Psychiatric Women Only Page 4
5 Patient Statement: To the best of my knowledge, the above information is accurate and complete and I acknowledge that I have been presented and read a copy of the Office Policies and The Practice's Notice of Privacy Practices in the new patient paperwork packet. Patient/Guarantor Signature Name and Number/Cross Streets: Pharmacy Information Emergency Contact Name: Phone Number: May we speak to your emergency contact if he/she contacts us on your behalf? O Yes O No Please list the names and phone numbers of those individuals involved in your care or with whom you will allow us to share your health and treatment information including family members and friends: (If none put N/A) Name: Phone: Relationship: Alternative Phone: Name: Phone: Relationship Alternative Phone: Name: Phone: Relationship: Alternative Phone: Michael Buckmire, MD Rita Hadley, MD Kevin Masur, MD Jennifer Reitz, MD Alvaro J. Testa Jr.,MD Susan Cortesi, MD Theodore Haley, MD Matthew Marini, MD Greg J. Rula, MD Jessica Swanson NP Lawrence Damore II, MD Sumeet Kadakia, MD Richard Oh, MD Mark Runfola, MD Rachel Sanders PAC Sarah Arnce PA-C 2945 S Dobson Rd, Mesa AZ Office: (480) Fax: (480) Rome S. St Suite 204, Gilbert AZ Office: (480) Fax: (480) Page 5
6 OPTIONAL Patient Request for Communications Patient Name: Date of Birth: Phone Number: Address: Communications over the Internet and/or using the system may not be encrypted and may not be secure. There is no assurance of confidentiality when communicated via . To request that this provider communicate with you via you must complete this form and return it to your health care provider s office. Please be advised that: (1) This request applies only to the healthcare provider or program that you indicate below. If you would like to request to communicate via with another health care provider or program, you must complete a separate request for that office. (2) Advanced Surgical Associates will not communicate health information that is specially protected under state and federal law (e.g. HIV/AIDS, substance abuse, and mental health information) via . (3) Your request will not be effective until you receive and respond to a test message. Please provide the answer to the question below for your test The street number of my Residence: I understand and agree to the following: I certify the address provided on this request is accurate, and that I accept full responsibility for messages sent to or from this address. I have read and understood the Patient Communication and I am able to request a copy of this form. I understand and acknowledge that communications over the Internet and/or using the system may not be encrypted and may not be secure; that there is no assurance of confidentiality of information when communication this way. I understand that all communications in which I engage may be forwarded to other provider for purposes of providing treatment to me. I agree to hold Advanced Surgical Associates and individuals associated with it harmless from any and all claims and liabilities arising from or related to this request to communicate via . Signature of patient or personal representative Date If personal representative, authority to act on Behalf of the patient Advanced Surgical Associates Name of Physician or Program 08/10/2016 Page 6
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
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Acknowledgement of receipt of notice of privacy practices
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New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
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SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )
PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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WELCOME TO OUR OFFICE
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3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
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PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
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CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
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Inner Balance Acupuncture
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Name of Recipient: Recipient s DOB (if known) Relationship to Recipient: (Example: mother, father, sister, brother, friend, etc)
The Christ Hospital Health Network DONOR REGISTRATION INFORMATION Phone: 513-585-2493 Fax: 513-585-0433 (Please be advised donor information is needed ONLY to register donor in the Christ Hospital system.
LAKES INTERNAL MEDICINE
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REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
PATIENT MEDICAL HISTORY PATIENT INFORMATION
PATIENT MEDICAL HISTORY PATIENT INFORMATION Name: Referred here by: Self Family Friend Doctor Other Health Professional If Doctor, please give name & address: List doctors seen in the last 24 months: Relative(s)
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION (PLEASE USE FULL LEGAL NAME, NO NICKNAMES) LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: E-MAIL ADDRESS:
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
Medical Questionnaire
Medical Questionnaire Date: Day Month Year Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty