TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
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1 TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates as your future Internal Medicine Provider. Our goal is to provide high quality care and be your partner in your quest for better health maintenance. To help in this endeavor we have included the New Patient Packet and request that you fill these forms out completely prior to your arrival for your appointment. Bring this along with your insurance card, photo identification and any old records that you have. We also request that you bring ALL your medications/supplements/over the counter medications that you take regularly to each and every appointment. This is imperative in verifying medication doses, preventing medication and communication errors, and providing refills. In order to verify all of the above information and get you registered into our electronic medical record system, we request that you arrive to this first visit one hour ahead of your appointment time. We also request that if you must reschedule your appointment please do so 48 hours in advance. There is a fee for missed appointments if you do not call and cancel. If you have any questions please feel free to contact us ( ). We also request that you bring the names and phone numbers of all physicians that you see/have seen, current and past, so that we can request records to help us to better take care of your healthcare needs. We look forward to working with you. Sincerely, The providers and staff of Tomball Regional Internal Medicine Associates Your appointment is scheduled for at please arrive by. Thank you 1
2 TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES ACQUAINTANCE FORM Name Age Birthdate Mailing Address City State/Zip Home Address City State/Zip Phone (H) W C Sex: M F Race Marital Status: S M D W Separated SS # Driver s License # Employer Phone Address City State/Zip Referred by: Emergency Contacts: Relationship Name Phone Relationship Name Phone Relationship Insurance Information: Primary: Group # ID # Policy Holder: SS# Birthdate Employer: Address Secondary: Phone Group # ID # Policy Holder: SS# Birthdate Employer: Address Phone I assume full responsibility for payment of all service rendered not covered by my insurance plan. I authorize payment of medical benefits to the above named provider. I authorize the release of medical information/records to my health insurance company for the purpose of obtaining payment for services. Signature Date 2
3 TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX NAME Age DOB Physician * DRUG ALLERGIES: Today s Date 1. REASON FOR APPOINTMENT TODAY: 2. HAVE YOU EVER BEEN TOLD YOU HAVE ANY OF THE FOLLOWING: Yes No Year High Blood Pressure High Cholesterol Heart Disease Vascular Disease Diabetes Cancer If yes, what type? Bleeding Problems Stroke Arthritis COPD/Asthma Kidney Disease Thyroid Disease Mental Illness Other Medical Conditions If yes, list conditions: 3
4 SURGICAL HISTORY DATE 3. SOCIAL HISTORY Yes No Smoking Past Smoking History Quit Date: Chewing Tobacco Alcohol Use Caffeine Recreational Drug Use Occupation: Education Level: Single Married Widowed Divorced 4. FAMILY HISTORY Age Alive Health Issues Deceased Cause of Death Father Mother Brothers 1st 2nd 3rd Sisters 1st 2nd 3rd Have any of your family members been diagnosed with the follow conditions: Yes No Father Mother Sibling High Blood Pressure High Cholesterol Heart Disease Vascular Disease Cancer Stroke Diabetes Bleeding Disorders Kidney Disease Thyroid Disease Glaucoma Mental Illness Hearing Loss 4
5 Other medical conditions: If yes, list conditions: 5. HEALTH MAINTAINENCE HISTORY When was your last? EKG Stress Test Pacemaker Check Colonoscopy Mammogram Bone Density Scan PSA level (Male) TB Test Flu Vaccine Tetanus Vaccine Pneumonia Vaccine FOR DIABETES PATIENTS ONLY When was your last? Eye Exam Foot Exam Dental Exam HgbA1c Blood Test Urine - Microalbumin FOR WOMEN PATIENTS ONLY Menopause Age Last menstrual period Contraception use YES NO Last PAP Last Pelvic Exam How many pregnancies? How many children? Miscarriages Gestational Diabetes YES NO If yes, when? 5
6 ROS III - Please answer yes or no for all lines: Genitourinary Symptoms Dysuria (painful/difficulty urination) Increase Urinary frequency Hematuria (blood in urine) Dark color urine Other genitourinary symptoms Musculoskeletal Symptoms Joint pain, localized Joint stiffness, localized Muscle aches Other musculoskeletal symptoms Neurological Symptoms Skin Symptoms Y N Y N Dizziness Pruritus (itching) Skin lesions Rashes Other skin symptoms Vertigo Fainting (syncope) Motor disturbances Sensory disturbances Other neurological symptoms Endocrine Symptoms Y N Psychological Symptoms Excessive sweating Y N Excessive thirst Libido has changes (sexual desire) Other endocrine symtoms Sleep disturbances Anxiety Depression Other phychological symptoms
7 ROS II - Please answer yes or no for all lines Neck Symptoms Neck pain Neck stiffness Lumps or swelling in the neck Other neck symptoms Pulmonary Shortness of breath Cough Coughing up blood Wheezing Other pulmonary symptoms Breast Symptoms Y N Breast pain Nipple discharge Breast lump Other breast symptoms Cardiovascular Symptoms Chest pain/discomfort Fast heart rate Palpitations Other cardiovascular symptoms Gastrointestinal Symptoms Change in appetite Difficulty swallowing Heartburn Nausea Vomitting Abnominal Pain Diarrhea Black or bloody stool Other gastrointestinal symptoms
8 ROS I - Please answer yes or no for all lines Systemic Symptoms Weight change Chills Night Sweats Feeling tired/poorly (malaise) Other constitutional symptoms Eye Symptoms Eyesight problems Photophobia Eye pain Itching of eyes Other eye symptoms Head Symptoms Headache Facial pain Sinus pain Other head related symptoms Otolaryngeal Symptoms Earache Hearing loss Ringing in ears Nose bleed Nasal discharge Mouth sores Bleeding gums Hoarseness Throat pain Other otolaryngeal symptoms
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New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol