Patient Information Form

Transcription

1 Patient Information Form Patient Registration Information Name: First MI Maiden Last Home Phone: ( ) Work: ( ) Cell: ( ) Address: Street Apt City State Zip DOB: / / Age: Sex: Social Security #: Driver s License #: Reason for Visit: Emergency Contact: Relationship: Phone: ( ) Referred by: Phone: ( ) PCP: Name of Physician/Individual Name of Physician/Individual Marital Status Single Married Divorced Widowed Primary Insurance Information Insurance Company Name Policy # Group # Primary Insured Insured s DOB Insured s SS# Relationship to Patient Employer: Please present your card at each visit. Release Form & Preferred Method of Contact I,, give Satin Patel, M.D. and staff permission to speak with the following person regarding my health status, including diagnosis, treatment options and plans and payment for health services I receive from North Texas IVF. Name: Phone: Relationship: Can We Leave a Message? Please check your preferred method of contact if we need to contact you or leave a message regarding your care. Home Phone Cell Phone Work Phone North Texas IVF Satin Patel, M.D Walnut Hill Lane., Suite 114 Margot Perot Building Dallas TX GD /12 KS Patient Information Page 1

2 Assignment of Benefits/Release of Information/Notice of Privacy Practices/Appointment of Authorized Representative **Please read and initial each paragraph** North Texas IVF and associated physicians are committed to securing the privacy of your health information. We are supplying you with a copy of our Notice of Privacy Practices. You are not required to read this notice. By initialing, you are acknowledging receipt of this notice. I request that payment of authorized Medicare and other insurance benefits be made on my behalf to North Texas IVF for any services furnished to my by any healthcare providers associated with that group. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or insurance company any information needed to determine these benefits or the benefits payable for related services. I appoint North Texas IVF to act as my authorized representative in requesting an appeal from my insurance plan regarding its denial of services or denial of payment. Unless I request to the contrary in writing, I will accept appointment reminder s on my home telephone answering system and/or appointment reminder cards sent by mail, whichever is the poli cy of this practic. e Patient Financial Responsibility Statement In order to maintain our fees at the lowest possible level, it is important that we have a good understanding with our patient regarding financial responsibility. We hope that this summary will be helpful toward that end. We encourage you to discuss it with us and to ask questions. We understand that your health coverage is provided through If you have out-of-network benefits, we will happily file claims on your behalf. You must pay any co-payment and applicable deductible amounts at the time of service unless other arrangements have been made with our off ice.. The remainder of your bill will be sent to your health plan for direct payment to our office. If your insurance carrier has not paid our claim within 45 days, we will expect payment from you. If, by mistake, your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time. You will remain responsible for amounts and any services that are not covered by your insurance plan. Your health plan may refuse payment of a claim for some of the following reasons: 1) This is a pre-existing illness that is not covered by your plan 2) You have not met your full calendar year deductible 3) The type of medical service required is not covered by your plan 4) The health plan was not in effect at the time of service 5) You have other insurance which must be filed first Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as the patient to pay the denied amounts in full. Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way that health care is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care. With this housekeeping chore complete, we are pleased to serve you. Sincerely, Noth Texas IVF I have completed this form with accurate information and have read and understand my obligations. I acknowledge that I am fully responsible for supplying correct insurance information, billing information, and payment of any services not covered or approved by my insurance carrier. I consent to receive medical treatment from the physician(s) and/or other medical provider(s) of North Texas IVF Signature of Patient Date GD /12 KS Patient Information Page 2

3 New Patient Questionnaire Patient Name: Partner s Name: Date of Birth: Date of Birth: What concerns would you like addressed at your visit? Are you trying to conceive? If yes, for how many months/years without protection? Have you ever had an anaphylactic reaction or do you carry an epi pen? Please mark allergies and sensitivities to all that apply: Latex Iodine List any other medical allergies and your reaction below. Drug and/or Foods Contrast Albumin (egg) Reaction known Would you benefit from a translator? If yes, which language? How were you referred to our office? Physician Name: Address: Office number: Fax number: Friend/Patient: Internet: Community Talk: Printed media: Would you like to make us aware of any cultural or religious beliefs that would allow us to more effectively meet your medical needs? Have you been evaluated or treated for infertility previously? If yes, please fill out the next section marked infertility. If no, please skip to the section marked gynecologic history. GD /12 KS New Patient Questionnaire Page 1

4 Infertility Who is/was your doctor? Please describe the results of any of the following prior fertility evaluations you have had: Hysterosalpingogram (HSG): FSH blood test: Laparoscopy: Laparotomy: Hysteroscopy: Please mark all of the following medications you have previously taken during treatment: Tablets Clomiphene (Clomid) Letrozole/Anastrozole (Femara/Arimidex) Estrogen Progesterone Bromocriptine/Cabergoline (Parlodel/Dostinex) Antibiotics Metformin (Glucophage) Danacrine (Danazol) Injectable Medications Repronex Follistim/Gonal F/Bravelle hcg Lupron Ganirelix/Cetrotide Please describe any treatment cycles utilizing intrauterine insemination (IUI). Cycle # Date Medication regimen Outcome Please describe/list any treatment cycles utilizing in vitro fertilization (IVF). If the cycle required intracytoplasmic sperm injection (ICSI) or assisted hatching (AH), please mark it next to the cycle. Cycle # Date Medications # Oocytes Embryos Outcome Have you experienced any side effects or complications from your previous treatments? Blurry vision Depression Injection site reaction Hyperstimulation (OHSS) Paracentesis GD /12 KS New Patient Questionnaire Page 2

5 Gynecologic History Date of 1 st day of last menstrual period: Age of first menses: # days from 1 st day of period to 1 st day of next period: # days of bleeding during menses: # pads needed per day on heaviest day: Do you have cramping with your period? Please check all that apply: Absent Mild Moderate Date of last pap smear: Result: Severe Requires pain medication Date of last mammogram, if applicable: Please mark all that apply to you now or in the past: Ectopic pregnancy Syphilis HIV/AIDS Hepatitis Gonorrhea Chlamydia Herpes Human papilloma virus (HPV) Chicken pox Rubella (German measles) injection Ovarian cysts Other Abnormal pap/colposcopy LEEP Pelvic pain Endometriosis Painful intercourse Irregular or absent periods Hot flashes Vaginal dryness Lubricants for intercourse Excessive hair growth Fibroids How frequently are you having intercourse? Have you used basal body temperature or urinary ovulation kits? If so, what do they show? When have you last used contraception? What type were you using? GD /12 KS New Patient Questionnaire Page 3

6 Obstetrical History Please list all pregnancies including miscarriages and abortions in chronologic (time) order. Year Delivery Route Outcome Wks GEstation/Birth Wt Complications Vaginal, Abortion C-Section, D&C Medical History Please mark any of the following health conditions that affect you: Hypertension (high blood pressure) Diabetes Heart murmur Heart disease Pulmonary hypertension Asthma Crohn s disease or ulcerative colitis Thyroid disease Breast disease Appendicitis Cancer: type Radiatioon therapy Seizures Hemophilia or bleeding disorder DVT/PE (blood clots) Systemic lupus erythematosus Blood transfusions Frequent urinary tract infections Medications Please list all medications you are currently taking including over the counter, herbal, and alternative. Medication Name Dosage Route Frequency GD /12 KS New Patient Questionnaire Page 4

7 Surgeries and Hospitalizations Surgery or reason Date Surgeon or Doctor Hospital for hospitalization) Social History What is your occupation? How many cigarettes, if any, do you smoke or how much tobacco do you use? How many alcoholic beverages, if any, do you consume? What types of illicit/recreational drugs, if any, do you use or have you used in the past? Family History What is your ethnic background (Chinese, Ashkenazi, Jewish, Brazilian, etc.)? Have you OR your partner had any children (living or dead) with a birth defect, mental retardation or serious health problem (include any children from you and/or your partner s previous relationships/marriages)? If so, please describe. Were you OR your partner born with any birth defects (congenital heart defect, cleft palate, etc.)? If so, please describe. Please mark all that apply to your family OR your partner s family members. High blood pressure Diabetes Kidney disease Thyroid disease Cancer: type Cystic fibrosis Muscular dystrophy Down s syndrome Tuberous sclerosis Tay-Sachs Sickle cell anemia Deafness Blindness Early menopause Mental retardation Recurrent miscarriage Iinfertility Chromosome problem GD /12 KS New Patient Questionnaire Page 5

8 Please indicate any diseases for which you have been tested. Tay-Sachs Sickle cell disease or trait Canavan s Fragile X Gaucher s Cystic fibrosis Thalassemia Review of Systems Please check all that apply to you. Fatigue Weight gain or loss >15lbs Fever Blurriness Spots/floaters Glaucoma Deafness Kartagener s Neck swelling Palpitations Chest pain Dizziness on standing Shortness of breath Wheezing Coughing blood Headaches Loss of balance Paralysis Nausea/vomiting Diarrhea Constipation Abdominal pain Arthritis/joint pain Weakness Osteoporosis Thickening of fat on upper back Skin rash/discoloration Nipple discharge Purple stretch marks Breast lump Blood in urine Loss of urine Pain on urination Spotting between periods Depression Anxiety Hot flashes/night sweats Cold intolerance Excessive thirst Brittle hair/nails Excessive hair growth Difficulty clotting Frequent nose bleeds Swollen lymph nodes Seasonal allergies Frequent infections Office use only: Physician Signature: Date: GD /12 KS New Patient Questionnaire Page 6

9 Partner History Patient Name: Date of Birth: Allergies List any other medical allergies and your reaction below: Drug Reaction known Medical History Please mark any of the following health conditions that have ever affected you: Medications High blood pressure/heart disease Diabetes Mumps Testicular injury Erectile/sexual dysfunction Cancer: type Radiation therapy Crohn s disease or ulcerative colitis Please list all medications you are taking including over the counter, herbal and alternative. Medication Name Dosage Route Frequency Surgical History Please list all surgeries or major hospitalizations in chronologic order. Surgery or Reason Date Surgeon or Doctor Hospital for Hospitalization GD /12 KS New Patient Questionnaire Page 7

10 Social History What is your occupation? How many cigarettes, if any, do you smoke or how much tobacco do you use? How many alcoholic beverages, if any, do you consume? What types of illicit/recreational drugs, if any, do you use or have you used in the past? Family History What is your ethnic background (Chinese, Ashkenazi, Jewish, Brazilian, etc.)? Please indicate any diseases for which you have been tested. Tay-Sachs Sickle cell disease or trait Canavan s Fragile X Gaucher s Cystic fibrosis Thalassemia Reproductive History Have you had a semen analysis? If so, please provide sperm count, percent motility, percent normal forms, & volume : How many pregnancies have you biologically fathered with your current partner? How many pregnancies have you biologically fathered with past partners? GD /12 KS New Patient Questionnaire Page 8

11 Review of Systems Please check all that apply to you. Fatigue Weight gain or loss >15lbs Fever Blurriness Spots/floaters Glaucoma Deafness Kartagener s Neck swelling Palpitations Chest pain Dizziness on standing Shortness of breath Wheezing Coughing blood Headaches Loss of balance Paralysis Nausea/vomiting Diarrhea Constipation Abdominal pain Arthritis/joint pain Weakness Thickening of fat on upper back Skin rash/discoloration Nipple discharge Blood in urine Loss of urine Pain on urination Difficulty urinating Depression Anxiety Hot flashes/night sweats Cold intolerance Excessive thirst Brittle hair/nails Excessive hair growth Difficulty clotting Frequent nose bleeds Swollen lymph nodes Seasonal allergies Frequent infections Office use only: Physician Signature: Date: GD /12 KS New Patient Questionnaire Page 9