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1 Keeping You in Sight 479 Heywood Ave. Spartanburg, SC Phone: Fax: Dr. Billy J. Haguewood, Jr. Dr. Brice B. Dille Dr. K. Leanne Wickliffe Dr. Jake P. Bostrom Dr. J. Steve McPhail Name: Mailing Address: City: State: Zip: Home#: Work#: Cell#: Preferred Language: Social Security #: Date of Birth: Ethnicity: Hispanic or n-hispanic (Circle Choice) Medical Primary Insurance Co: Policy: Medical Secondary Insurance Co: Policy: Please Print Patient Information Sex: Male or Female Insurance Information: Appointment Information: Race: Asian African American Caucasian Bi-Racial Other (Circle Choice) Marital Status: Single Married Separated Divorced Widow (Circle Choice) Primary Care Physician: Referring Physician: Spouse/Parent Name: Phone #: Nearest Relative NOT Living With You: Relationship: Insured s Name: Insured s Social Security #: Insured s Date of Birth: Employer: Retired How would you like to receive future appointment reminders: Text Phone Call Address: Phone #: I request that payment of authorized Medicare and/or other Insurance benefits be made on my behalf to my physician for services rendered to me. I further authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents and/or to other insurance administrators any information needed to determine these benefits or the benefits payable for related services. I also authorize the release of any medical records from any health care provider to this physician for the purposes of providing coordinated healthcare services to me. And I authorize the release of any medical records from this physician to any healthcare provider for coordination of my medical care. Payment in full is required when services are rendered if there is no insurance coverage. You will be responsible for any portion of your bill which is not paid for by your insurance company. Patient Signature: Date: OR Authorized Patient Signature: Signature: Relationship to patient: Date: **Continue to Back**
2 Keeping You in Sight Patient Name: Date: ID Number: 1. Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? Yes If yes, When? 2. Do you ever experience any of the following symptoms? Redness Scratchy feeling Burning Tired eyes, eye fatigue Foreign body sensation Fluctuating Vision Itching Excess tearing/watering eyes Stringy mucus in or around the eyes Contact lens discomfort 3. Are your symptoms related to or made worse by any of the following factors? Windy conditions Places with humidity Areas that are air conditioned/heated More than 2 hours of computer/pda use per day There are several methods for treating dry eye symptoms: over the counter tears prescription eye drops/ointments massaging your eyelids eyelid cleaners omega-3 fatty acids treatment to unblock Meibomian Glands (Lipiflow) tear duct plugs Tears keep your eyes healthy and comfortable. Your doctor may suggest one or a combination of the above methods to treat your dry eye symptoms. Do any of the following issues concern you? Facial fine lines/wrinkles Crow s feet Laugh lines Acne/blemishes/dark spots Anti-aging skin care Length/fullness of eyelashes Drooping eyelids/brow
3 MEDICAL HISTORY QUESTIONNAIRE Name: Date of Birth: / / Medical Record # Primary Care Physician Pharmacy: Location(street & city) Medication Allergies: Reaction Severity Past Ocular History: (Please mark all that apply) Overall Healthy Cataracts Optic Neuritis Macular Degeneration Amblyopia (Lazy eye) Diabetic Retinopathy Iritis Glaucoma Dry Eyes Keratoconus Retinal Detachment Ocular Surgeries: (Please mark all that apply) prior ocular surgery Corneal Transplant PRK Vitrectomy Blepharoplasty Retinal Laser Surgery RK Cataract Surgery LASIK Strabismus Surgery (eye muscle surgery) Ocular Significant Illnesses: (Please mark all that apply) Overall Healthy Graves Disease Lupus Sjogrens AIDS/HIV Herpes Multiple Sclerosis Thyroid Problems Diabetes Hypertension Rheumatoid Arthritis Current Eye Medications: (Please list) Systemic Illnesses: history of illnesses Congestive Heart Failure Hepatitis Lung Disease Anemia COPD High Blood Pressure Lupus Arthritis Diabetes High Cholesterol Migraine Arrhythmia Eczema HIV Polymyalgia Asthma Fibromyalgia Kidney Disease Psychiatric Disorder Bleeding Disorder Headache Kidney Stones Skin Cancer Cancer Hearing Loss Liver Disease Stroke Thyroid Disease Menopause General Surgeries / Operations: (Please list) Please continue on the back side of this page
4 Current Other Medications: (Please list) Infections: (Please mark all that apply) Overall Healthy Cold Sores HIV / AIDS Herpes Zoster / Shingles Hepatitis A / B / C Meningitis MRSA Family History and Relationship to Family Member: Diabetes Stroke High Blood Pressure Glaucoma Lazy Eye Macular Degeneration Cancer Heart Disease Retinal Disease Social History: (Please mark all that apply) Smoking: current every day smoker former smoker never smoked Alcohol Use: Yes If yes how much and how often? Drug Use: Yes If yes what and how often? Review of Systems: (Please mark all that apply) Eyes Previous Surgery Contact Lens Pain Double Vision Glaucoma Cataracts Macular Degeneration Dry Eyes Flashes Floaters Ear, se, and Throat Hard of Hearing Ringing in Ears Vertigo Cardiovascular Chest Pain Dizziness Fainting Spells Shortness of Breath Irregular Heart Beat Difficulty Lying Flat Constitutional Fatigue / Weakness Fever Weight Gain / Loss Respiratory Cough Congestion Wheezing Asthma Gastrointestinal Heartburn Nausea / Vomiting Jaundice / Hepatitus Genito-Urinary Pain / Difficulty Blood in Urine History of Kidney Stones History of STD s Psychiatric Anxiety / Depression Mood Swings Difficulty Sleeping Endocrine Increased Thirst Increased Hunger Increased Urination Increased Sweating Fingernail Changes Blood / Lymphnodes Easy Bruising Gums Bleed Easy Prolonged Bleeding Blood Thinners/Asprin MusculoSkeletal Stiffness Arthritis Joint Pain / Swelling Skin Rash / Sores Lesions Hives / Eczema Neurological Seizures Weakness / Paralysis Numbness Tremors Immunologic Hives Itching
5
6 Keeping You in Sight Activity of Daily Living Patient Name: Acct : Please circle Yes or to each question that applies: Have you been bothered by: Yes How Long: Comments: Blurry/Cloudy Vision Yes A decline in vision Yes Sensitivity to light Yes Seeing rings or halos around lights Yes Glare or poor night vision Yes Difficulty driving during the day Yes Difficulty driving at night Yes Seeing road signs Yes Reading newspapers/books Yes Seeing the computer Yes Watching TV Yes Doing fine handwork/puzzles Yes Seeing double Yes
7 Dry eyes Yes Hobbies: Patient s Signature: Date:
Name: Sex: Male Female Date of Birth: / / Age: Home Phone: ( ) - Cell: ( ) -
PATIENT REGISTRATION Name: Sex: Male Female Date of Birth: / / Age: SS# Marital Status: Single Married Widowed Divorced Address City State Zip Home Phone: ( ) - Cell: ( ) - Email: How would you like to
EDWARD M STROH MD PC RETINA New Patient Packet
EDWARD M STROH MD PC RETINA New Patient Packet PATIENT INFORMATION First Name Middle Last Birth Date / / Age Gender: MALE FEMALE Street Address City State Zip Home Phone Employer Cell Phone Other Phone
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: (First) (Middle) (Last) Birth Date: _ Social Security Number: _ Address: _Apartment #: City: State: Zip Code: Home#: Work# Cell#:_ Marital Status: Single Married Divorced
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM B S M R W A G KS MAC Z GR SO ZA L Please tell us about yourself so we can help you make the best decisions about your care. Date: Social Security #: E-mail: Name: MR / MRS / MS
Please arrive fifteen minutes early so that we may prepare your medical information for your visit. Allow about one and a half hours for your visit.
Dear New Patient, Thank you for choosing Ford Eye Center for your eye care needs. The doctors and staff look forward to introducing you to the benefits of quality eye care. Our team is devoted to making
LASIK EXAM INFORMATION LASIK PROCEDURE INFORMATION
LASIK EXAM INFORMATION Thank you for choosing Castleman Eye Center for your LASIK evaluation. What to expect: 1. Your consultation with our ophthalmologist will last approximately 2 hours. 2. To perform
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Retinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
LECOM Health Ophthalmology
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
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Immediate Family History Please list Father, Mother, Brother, Sister or Children
: Social Security # Name: of Birth: Age: Address: City: State: Zip: Home#: Cell#: Work#: E-mail: Status: Married Single Divorced Widowed Work Place/School: Occupation/Grade: Emergency Contact (Name/Phone):
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
PATIENT REGISTRATION INFORMATION. Please Print
PATIENT REGISTRATION INFORMATION Please Print Dr. Mrs. Ms. Mr. First Name M.I. Last Sex: M F SS# Date of Birth / / Age Marital Status: Married Single Divorced Widowed If married, spouse s name: Mailing
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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:
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
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NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
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
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
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
Patient Interview Form
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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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:
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
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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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:
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information
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George M. Salib, M.D., Inc.
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Welcome. Medical History Do you have any allergies to medications? No Yes If Yes, Please Explain
Welcome Name: Address: City: State: Zip: Employer: Occupation: Birthdate: / / Social Security #: - - Name of Primary Care Physician: Guardian (If Applicable): Today s Date: / / Cell Phone: - - Home Phone:
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
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NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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