PATIENT INFORMATION. Patient Name: Address: Street Apt # City State Zip Code County. Phone #: Home Work Cell/Other Primary.
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1 PATIENT INFORMATION Patient Name: DOB: Marital Status: Preferred Pharmacy: Ethnicity (circle one): African American American Indian Asian Primary Language: Caucasian/White Hawaiian Hispanic/Latino Other Address: Street Apt # City State Zip Code County Phone #: Home Work Cell/Other Primary Address: Emergency Contact: Name Relationship DOB Phone # Insurance Information: Insurance Company Name: Insurance ID #: Group #: Insurance Claim Address: Policy Holder: Last First Middle DOB Address: SAME? Street Apt # City State Zip Code (check here) Phone #: Home Work Cell/Other How did you hear about us? Employer: Word of Mouth Facebook Instagram Yelp Health Grades Radio Web Search Community Newsletter Other: Preferred Method of Communication: Mail - Cellphone - Home Phone - Work Phone
2 Electronic Communication By supplying my home/mobile phone number, address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach & messaging system to use my personal information., the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, missed appointment, overdue wellness visit, or any other reasonable healthcare related communication. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information regarding healthcare events, unpaid balances, missed appointments, and to leave a reminder message on my voice mail or answering system if I am unavailable at the number provided by me. Initials Signature: Date:
3 Fee Service: BAMM service fees are $175 (regular business hours), $225 (house-calls) and $350 (after hours and holidays); (cash or credit card) at the end of the visit. If you are an annual member ($1750 annually) you will have unlimited visits for the calendar year. By signing below you understand this policy. Patient Signature:
4 CONSENT FOR RELEASE OF INFORMATION Patient Name: Date of Birth: Cell Phone#: Please check the sections that apply, then sign at the bottom of the page: I do not give BAMM permission to release my information to anyone other than myself. or I give BAMM permission to release my information that includes: Entire Medical Record Blood Tests X-rays Cultures, including throat, urine and genital Appointment Details Billing Information with My spouse or significant other (Name Other family member (Name On home answering machine or cell phone # On office/work voice mail # ) ) I also give permission to receive all information by mail to address: Signature: Date: (A signature is required for this form to be considered valid
5 Patient Auto-Payment Agreement For your convenience we are offering a patient balance payment option. This option is designed to help you pay your bill on time every time. You are not required to fill this form out if you do not wish to participate in our Auto-Payment program. I understand that in the event my credit card or debit card has been charged for medical services. I hereby authorize BAY AREA MEN'S MEDICAL CENTER and its designated payment system to charge my credit or debit card the full amount of charges for medical services provided. The amount charged will be reflected on my credit / debit card statement. If payment is denied by my payment card company or bank, I agree to pay the entire amount promptly via another form of payment. Patient Name: Patient Date of Birth: Signature: Date:
6 MALE HEALTH HISTORY FORM Today s Date: Name: DOB: Previous Primary Care Physician: Other physicians (specialists) involved in your care: Preferred pharmacy: MEDICAL HISTORY: Have you been diagnosed with any of the following? Alcoholism! Yes! Allergies! Yes! Anemia! Yes! Anxiety! Yes! Arthritis! Yes! Asthma! Yes! Back pain! Yes! Blood clots! Yes! If yes: where? Cancer! Yes! If yes: what type? Chrohn s / Ulcerative colitis! Yes! Depression! Yes! Diabetes! Yes! If yes: what type?! 1! 2 Emphysema / Lung disease! Yes! Eye disease! Yes! If yes: what type? Fractures! Yes! If yes: where? Gout! Yes! Migraines! Yes! Hearing loss / Ear problems! Yes! Heart attack! Yes! Heart disease! Yes! If yes: what type? Hepatitis! Yes! If yes: what type? (A, B, C) Hernia! Yes! If yes: what type? High blood pressure! Yes! High Cholesterol! Yes! HIV! Yes! HPV infection! Yes! Incontinence! Yes! Insomnia! Yes! Kidney disease! Yes! Kidney stones! Yes! ALLERGIES: Are you allergic to any medications?! Yes! If yes, please list the name(s) and type of reaction NAME Osteoporosis! Yes! Prostate enlargement! Yes! Stomach Reflux! Yes! Seizures! Yes! Sleep apnea! Yes! STDs! Yes! Stroke! Yes! Stomach ulcers! Yes! Thyroid disease! Yes! If yes: what type? Testicular torsion! Yes! Tuberculosis! Yes! Urinary tract infections! Yes! SURGICAL HISTORY: Have you had any of the following? Abdominal surgery! Yes! Appendectomy! Yes! Brain surgery! Yes! Back surgery! Yes! If yes: what type? Bladder surgery! Yes! Cosmetic surgery! Yes! If yes: what type? Eye surgery! Yes! If yes: what type? Gallbladder removal! Yes! Heart surgery! Yes! If yes: what type? Hernia repair! Yes! If yes: what type? Prostate surgery! Yes! Thyroid surgery! Yes! If yes: what type? Vasectomy! Yes! Other surgical history? REACTION 1/2
7 MEDICATIONS: Do you currently take any prescription medications:! Yes! MEDICATION NAME STRENGTH & DOSE FREQUENCY Do you take any over-the-counter supplements? (Calcium, multivitamins, sleep aids, other supplements)!! Yes - FAMILY HISTORY:! Unknown / Adopted Family Member Alcoholism Breast Cancer Bleeding Problems Colon cancer COPD Crohn s/ Ulc Colitis Diabetes Glaucoma Heart attack Heart failure High cholesterol High blood pressure Kidney disease Lung cancer Lupus Mental illness Ovarian cancer Pancreatic cancer Prostate cancer Rheum. arthritis Stroke Thyroid disease Tuberculosis Mother!!!!!!!!!!!!!!!!!!!!!!! Father!!!!!!!!!!!!!!!!!!!!!!! Sister!!!!!!!!!!!!!!!!!!!!!!! Brother!!!!!!!!!!!!!!!!!!!!!!! Maternal grandfather!!!!!!!!!!!!!!!!!!!!!!! Mat. grandmother!!!!!!!!!!!!!!!!!!!!!!! Paternal grandfather!!!!!!!!!!!!!!!!!!!!!!! Pat. grandmother!!!!!!!!!!!!!!!!!!!!!!! SOCIAL HISTORY: Marital status: Occupation: Current tobacco use! Yes!! Previously but quit: (date) Packs per day Years of use: yrs Type:! Cigarettes! Cigars! Chewing! Dip! Pipe! E-cigarettes Exposure to second hand smoke?! Yes! Alcohol use! Yes! If yes: # drinks / week Type of alcohol Are you or others concerned about your drinking?! Yes! HEALTH MAINTENANCE: If you ve had any of the following please specify date last performed: Prostate exam PSA Colonoscopy - Result:! rmal! Polyps! Diverticula! Hemorrhoids! Other: Dental exam Eye exam Tetanus shot HPV series (3) Flu shot Drug use! Yes! If yes: type Do you practice any religion! Yes! If yes, which one? Do you exercise?! Yes! How often? times/week What type of exercise? Are you currently sexually active? Yes Partner (s): Male Female Both Do you use protection? Yes 2/2
8 SEXUAL HEALTH INVENTORY FOR MEN (SHIM) PATIENT NAME: TODAY S DATE: PATIENT INSTRUCTIONS: Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question. OVER THE PAST 6 MONTHS: 1. How do you rate your confidence that you could get and keep an VERY LOW LOW MODERATE HIGH VERY HIGH erection? When you had A FEW TIMES MOST TIMES SOMETIMES ALMOST erections with sexual NO SEXUAL ALMOST NEVER (MUCH LESS (MUCH MORE (ABOUT HALF ALWAYS OR stimulation, how often ACTIVITY OR NEVER THAN HALF THE THAN, HALF THE THE ALWAYS were your erections hard enough for penetration (entering your partner)? A FEW TIMES MOST TIMES 3. During sexual DID NOT SOMETIMES ALMOST ALMOST NEVER (MUCH LESS (MUCH MORE intercourse, how often ATTEMPT (ABOUT HALF ALWAYS OR OR NEVER THAN HALF THE THAN, HALF THE were you able to INTERCOURSE THE ALWAYS maintain your erection after you had penetrated (entered) your partner? 4. During sexual DID NOT EXTREMELY VERY SLIGHTLY intercourse, how difficult ATTEMPT DIFFICULT DIFFICULT DIFFICULT DIFFICULT was it to maintain your INTERCOURSE NOT DIFFICULT erection to completion of intercourse? 5. When you attempted sexual intercourse, how often was it satisfactory for you? DID NOT ATTEMPT INTERCOURSE ALMOST NEVER OR NEVER A FEW TIMES (MUCH LESS THAN HALF THE SOMETIMES (ABOUT HALF THE MOST TIMES (MUCH MORE THAN, HALF THE ALMOST ALWAYS OR ALWAYS Add the numbers corresponding to questions 1-5. TOTAL: The Sexual Health Inventory for Men further classifies ED severity with the following breakpoints: 1-7 Severe ED 8-11 Moderate ED Mild to Moderate ED Mild ED
9 Less More Patient Name: Date: t At All Less Than 1 Time In 5 Than Half The Time About Half The Time Than Half The Time Almost Always YOUR SCORE 1. Incomplete Emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? 2. Frequency Over the past month, how often have you had to urinate again less than two hours after you have finished urinating? 3. Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? 4. Urgency Over the past month, how often have you found it difficult to postpone urination? 5. Weak Stream Over the last month, how often have you had a weak urinary stream? 6. Straining Over the past month, how often have you had to push or strain to begin urination? ne Once Twice 3 times 4 times 5 or more YOUR SCORE 7. cturia Over the past month how many times did you most typically get up each night to urinate from the time you went to bed until the time you got up in the morning? Total I-PSS Score Quality of Life due to Urinary Symptoms Delighted Pleased Mostly satisfied Mixed Mostly unhappy Unhappy Terrible If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? 6 The I-PSS is based on the answers to seven questions concerning urinary symptoms. Each question is assigned points from 0 to 5 indicating increasing severity of the particular symptom. The total score can therefore range from 0 to 35 (asymptomatic to very symptomatic). Although there are presently no standard recommendations into grading patients with mild, moderate or severe symptoms, patients can be tentatively classified as follows: 0-7 = mildly symptomatic; 8-19 = moderately symptomatic; = severely symptomatic. INTERNATIONAL PROSTATE SYMPTOM SCORE
10 ADAM Questionnaire Fill in the answers below and create a PDF to print out and take to your doctor. The Androgen Deficiency in Aging Male Questionnaire is a series of questions that can reliably lead clinicians to the possible diagnosis of low testosterone. If the answers to this questionnaire indicate that a low testosterone level is a possibility, the next step is to arrange a blood test for the patient to measure the testosterone level in the morning. Patient Name: Patient Age: Do you have a decrease in libido (sex drive)? Do you lack energy? Do you have a decrease in strength and /or endurance? Have you lost weight? Have you noticed a decreased enjoyment of life? Are you sad and /or grumpy? Are your erections less strong or not getting daily morning erections? Have you noticed a recent deterioration in your ability to play sports? Are you falling asleep after dinner? Has there been a recent deterioration in your work performance?
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Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
PATIENT INFORMATION. Name Maiden Name Last First MI. Sex: M F Age Birthdate SSN - - Martial Status. Address
PATIENT INFORMATION Date Name Maiden Name Last First MI Sex: M F Age Birthdate SSN - - Martial Status Address City State Zip Home Phone Cell Phone Email Address Contact preference: Race Preferred Language
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET
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
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS
Do you currently have a family physician?: If not, where have you been getting health care?:
Adult Intake Form Preferred Location: Cambridge Kitchener Apply Patient Label here First Name: Last Name: Gender: Address: Phone number: Date of Birth: Health Card Number:_ Do you currently have a family
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
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Lehigh Valley Physician Group
Lehigh Valley Physician Group Welcome to LVPG Obstetrics and Gynecology We are pleased you have selected LVPG Obstetrics and Gynecology for your obstetrical / gynecological care. Meeting a new medical
Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
PATIENT REGISTRATION FORM
Please Print PATIENT REGISTRATION FORM Date: Who can we thank for referring you to our office? Patient Name (First) (Middle) (Last) Preferred Name (if applicable) DOB Sex: Male Female Patients Address
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
RESEARCH PARTICIPANT REGISTRATION FORM
RESEARCH PARTICIPANT REGISTRATION FORM PATIENT: DOB: AGE: DATE: Last Name First Name M.I. ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK PHONE: MOBILE: SOCIAL SECURITY NUMBER # (Why are we asking for this?*):
PATIENT DEMOGRAPHIC AND HISTORY. PATIENT INFORMATION (Please Print) Today s Date: / /
PATIENT DEMOGRAPHIC AND HISTORY PATIENT INFORMATION (Please Print) Today s Date: / / Name: Mailing Address: City/State/Zip Home phone Work Phone Cell Phone Ok to leave message: yes No Ok to leave message:
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?
Adult Health History Legal Name: First Last Name you like to be called: Date of Birth: Legal sex: Male Female X Gender: Woman Man Trans Woman Trans Man Non-binary Genderqueer Agender Not Listed: Filling
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.
Welcome! This form helps us to meet your medical needs and to provide the best service to you. If you have any questions or need assistance, please ask us. GENERAL PATIENT INFORMATION Name: Home Phone:
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are