Welcome to Decatur County Memorial Hospital Physician Practices Important Information for New Patients of Primary Care and Tree City Medical:
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1 Welcome to Decatur County Memorial Hospital Physician Practices Important Information for New Patients of Primary Care and Tree City Medical: For all new patients: Please arrive 30 minutes prior to your appointment time in order to allow sufficient time to complete necessary paperwork, enter your information into our system, and update your past medical history. Please bring ALL bottles for all medications and supplements that you are taking. This helps us make sure that our information is as accurate as possible. At your first appointment, your provider will review your past medical history and your current health status with you. The more information we have, the better care we can provide. Please be ready to provide a detailed medical history, including any previous surgeries, health issues, and family history. Please have the names and contact information for all previous medical care providers at your visit so that we can obtain records. It is best if you complete a Release of Information form (ROI) with these providers ahead of time, in order to have your records available at the time of your first visit. If your insurance requires a co-pay, we will be collecting that payment at the time of check-in for your first visit. Please be sure to bring an appropriate form of payment. We accept cash, check, and credit cards (except American Express). Please bring your identification and insurance card(s) to all visits so that we always have the most updated information. For new patients who are currently on narcotic prescriptions (also known as controlled substances): Our providers WILL NOT be dispensing new narcotic prescriptions or refilling current narcotic prescriptions at the first visit. You will need to contact your previous provider for any refill needs. If your provider decides that narcotic prescriptions are medically indicated for treatment of your condition(s), then you may be asked to complete a controlled substance agreement outlining additional terms related to these prescriptions. Violation of this agreement may result in your dismissal from both Primary Care and Tree City Medical practices. We look forward to caring for you and helping you stay in good health! Decatur County Primary Care Physicians & Nurse Practitioners 718 N Lincoln St, Greensburg phone: Dr. Nicole Boersma Dr. Purnendu Datta Dr. Anjum Fazlani Dr. Jami Rayles Dr. Andy Tran Dr. Cody Wagner Tracy Ingram, NP Rebecca Lovins, NP Emily McNulty, NP Tree City Medical Physicians & Nurse Practitioners 955 N Michigan Ave, Greensburg phone: Dr. Arthur Alunday Dr. Jennifer Fletcher Dr. Mary McCullough Dr. Noel Mungcal Suzi Johannigman, NP Natasha Struewing, NP Cary Troutman, NP Shelly Walsman, NP CLN-060-X, p. 1 of 6
2 Decatur County Memorial Hospital Physician Practices New Patient Demographic Form Legal Name: Preferred Name: LAST FIRST MI Date of Birth: / / Age: Legal Sex: M F Gender Identity: Social Security Number: Primary Language: English Other: Ethnicity (please select one): Hispanic or LaEno Not Hispanic or LaEno Race (please select the one category you feel best represents you): American Indian or Alaskan Native Asian Black or African American NaEve Hawaiian or Pacific Islander White Marital Status: Single Married Long-term Partnership, not married Separated Divorced Widowed Contact Information Address: City: State: Zip: Home Phone # Work Phone # Cell Phone # How would you prefer to be contacted during the day? Home Work Cell Can we leave a detailed message on your voic or answering machine? Yes No address: We can use your address to sign you up for our patient portal, which allows you to view your lab results and clinical information online, and to message your provider. May we register you for the portal? Yes No Insurance and Payment Information Guarantor: Self Other (enter information below) Name: DOB: / / SSN: Guarantor Contact Information Address: City: State: Employer: Home Phone # Work Phone # Cell Phone # Primary Insurance Provider: Group/Policy #: Policy Holder s Information: Name: DOB: / / Place of Employment: Relationship to You: Self Spouse Parent Child Secondary Insurance Provider: Group/Policy #: Policy Holder s Information: Name: DOB: / / Place of Employment: Relationship to You: Self Spouse Parent Child With my signature, I certify that the above information is correct to the best of my knowledge. Patient/Guardian Signature: Date: / / CLN-060-X, p. 2 of 6
3 Decatur County Memorial Hospital Physician Practices New Patient Information Form Please complete as much as you are able. Having your full health history will help your provider to give you better care. Legal Name: Preferred Name: LAST FIRST MI Date of Birth: / / Age: Legal Sex: M F Gender Identity: What is your main concern today? Allergies you Have and Medications you are Taking Allergies and Medication Reactions: (please list reactions to medications if you know them) Medicines (including dose and how often they are taken): (please include over-the-counter meds, vitamins, herbs and supplements) CLN-060-X, p. 3 of 6
4 Your Medical History Please mark all conditions that you have or had in the past. Now Past Acid Reflux/GERD ADHD Alcohol/Substance Abuse Anemia Anxiety Arthritis Asthma Autoimmune Issues Back Pain/Disc Disease Bipolar Disorder Bladder Problems Bleeding Problems Breast Problems Cancer (type: ) Cataracts Congestive Heart Failure COPD/Emphysema Coronary Artery Disease Crohn s Disease Dementia Depression Diabetes (on insulin? Yes No ) Diverticulitis DVT/Blood Clot Erectile Dysfunction Glaucoma Heart Attacks/MI Hepatitis High Blood Pressure Now Past High Cholesterol HIV Irritable Bowel Syndrome Lupus Liver Disease Kidney Disease Kidney Stones Macular Degeneration Menopause Miscarriage (number: ) Abortion (number: ) Neuropathy/Nerve Pain Osteoporosis/Osteopenia Parkinson s Disease Peripheral Vascular Disease Pregnancy (number: ) Prostate Problems Psoriasis Pulmonary Embolism Rheumatoid Arthritis Seizures Sleep Apnea Skin Ulcers Stroke Stomach Ulcers Thyroid Problems Tuberculosis Ulcerative Colitis Urinary Incontinence DCMH New Patient Information Form for (your name): CLN-060-X, p. 4 of 6 Medical Conditions you have that are not listed above:
5 Your Surgical History Please list all surgeries that you have had and include approximate dates, if known Your Family History Please be as complete as you can. Age Still Living? Cause of Death Medical or Psychiatric Conditions Father Mother Brothers/Sisters Grandparents Any family history of birth defects or genetic diseases? Please be as specific as you can. Other Family Members not listed with Significant Medical Issues: DCMH New Patient Information Form for (your name): CLN-060-X, p. 5 of 6
6 Your Social History: Do you currently smoke or use other tobacco products? Yes No, but I have in the past No, never What do you use? CigareLes Pipe Cigars e-cigarettes Chewing tobacco Other: When did you start using tobacco? How much did/do you use? If you have quit smoking, when? If not, have you considered quitting? Yes No Do you currently drink alcohol? Yes No, but I have in the past No, never How much alcohol do you drink? Daily, 0-2 drinks per day Daily, more than 2 drinks per day A few Emes a week A few Emes a month Holidays and special occasions only Other: Do you use marijuana or other drugs, including medications prescribed for someone else? Yes No, but I have in the past No, never Prefer not to respond What have you used? Marijuana Cocaine/crack Heroin Amphetamines Tranquilizers SedaEves Painkillers Club or Designer Drugs Inhalants IV drugs Methamphetamine PrescripEon MedicaEons Unknown/Not Sure Other: When did you last see a doctor? Other Healthcare Providers: What was that visit for? Do you see any specialists or other healthcare providers (cardiologist, mental health provider, kidney doctor, dentist, chiropractor, etc)? If so, please provide names and locations so we can coordinate your care with them. Last Bone Density Scan: Normal Abnormal Preventive Care: Last Colonoscopy: Normal Abnormal When was your last tetanus shot (year)? Pneumonia shot? Flu shot? Last menstrual period: Are your periods regular? Yes (how omen? ) No Last Pap Smear: Normal Abnormal Last Mammogram: Normal Abnormal Have you had any blood work, x-rays, or other testing done in the last 6 months? Yes No When and where was it done? Are you sexually active? Yes, currently No, but I have been in the past No, I have never been Preferred sexual partners? Only Men Mostly Men, SomeEmes Women Both Men and Women Mostly Women, SomeEmes Men Only Women Are you or your partner(s) using birth control? Yes, condoms Yes, another type (what type? ) No, and I/we are planning to conceive No, and I/we are not planning to conceive Patient Signature: Date: / / DCMH New Patient Information Form for (your name): CLN-060-X, p. 6 of 6
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PATIENT INFORMATION. Name Maiden Name Last First MI. Sex: M F Age Birthdate SSN - - Martial Status. Address
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HEALTH HISTORY FORM. Student PID Number Date of Birth Legal Sex Preferred Pronouns Relationship Status (ie. he/him, she/her, they/their)
2 Health Center Drive Athens, OH 45701 Tel: (740)593.1660 Fax: (740)593.0179 HEALTH HISTORY FORM Legal Name Last First Middle Initial Preferred Name Student PID Number Date of Birth Legal Sex Preferred
FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #
FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S
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
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
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
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
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS
Name: Birthdate: What is your main health concern today? Do you currently use tobacco? YES NO Have in the past? YES NO Year Quit If yes, what kind of tobacco?_number of years: Amount of tobacco per day:
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
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:
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
Name: Today s Date: Address: State, Zip Code
New Patient Health History Questionnaire Name: Today s Date: Address: City State, Zip Code Email Address: Date of Birth: Home Telephone #: Cell Number: Work Number: Emergency Contact name & number: Referred
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle
PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE Date of Appt: / / Name: Date of Birth: / / Last First Middle The information you provide today is very important in regards to your healthcare. Please answer
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More