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11 PHYSICAL EXAM HISTORY NAME Chart# AGE D.O.B. TODAY S DATE: I. CHIEF COMPLAINT: II. HISTORY OF PRESENT ILLNESS: III. PAST MEDICAL HISTORY Check ( ) all that apply Peripheral Arterial Disease Diverticulosis Asthma Heart Disease Venous Insufficiency/Statis TB COPD Heart Failure Diabetic Peripheral Neuropathy Cataracts Anemia High Blood Pressure Thyroid Disorder Glaucoma Arthritis Diabetes Carotid Stenosis Blindness Dizziness Stroke Cholesterol Senile Dementia Gout Prostate Hearing Loss/Impairment Osteoporosis Allergies Eczema Macular Degeneration Blindness Incontinence Cancer Psoriasis Chronic Liver Disease Kidney Stones Chemo/Rad Ulcers IV. MEDICATIONS V. ALLERGIES Allergies to Anesthesia: Yes No VI. PAST SURGICAL HISTORY VII. PAST HOSPITALIZATIONS VIII. SOCIAL HISTORY: IX. REVIEW OF SYSTEMS = Normal Married? Yes /No /Other Heent Monogamous? Yes /No /Homosexual? Pulmonary # Children Residence Cardiac Live Alone? Yes /No Retired? Yes /No GI Occupation: GU Industrial Exposures: GYN Ever Smoked? Yes /No Packs/Day #Years MS Alcohol Drinker? Yes /No Drinks/Day Last PAP Last Mammo Drug User? Yes /No Colonoscopy Calcium Suppl. Dental Exam UTD Eye Exam UTD Dietary Hx Exercise Drives Car? Yes No Seatbelts used Flu Vaccine Last DT Pneumovax? X. FAMILY HISTORY Mom Dad Sibs YES NO Who in Family? Premature C.A.D. Hypertension Diabetes Mellitus Thyroid Disorder Breast Cancer Colon Cancer Other ASSISTIVE DEVICES: Wheelchair: Electric Scooter: Walker: Cane: Crutches: Eyeglasses: Hearing Aids: Dentures:
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13 Suncoast Family Medical Associates Authorization for the Release of Information I hereby give my permission to (list physician/facility name and address): To release a copy of my Protected Health Information (PHI) to: Jeffrey S. Grove, D.O. Ty L. Tvedten, D.O. Samuel Pettina, D.O. N. Nicholas Engelman, D.O. Krista M. Keith, D.O. Eugene M. DiBetta, Jr., D.O. Enrique J. Urrutia, Jr., D.O. R.L. DaSo, D.C. I instruct the above named entity to produce the following information: (Check ONE only) Release entire record I would like specific records released: Please forward records to the following location: Seminole Blvd. Largo, FL (727) (727) fax Unless otherwise noted this authorization expires one year from date signed. My PHI is to be disclosed for: Continuation of care Other The undersigned is a patient of Suncoast Family Medical Associates or an authorized representative of the patient and requests that the above named facility to release any and all information which the named facility may possess in regard to the patient s examinations and treatments, including but not limited to, alcohol abuse or drug abuse information, HIV antibody testing information, psychiatric and/or psychological information, communicable disease information, or any other information related to the patient s total treatment, unless specified below, which may be a part of the medical records. I may revoke this authorization at any time by mailing or personally delivering a signed, written notice of revocation to the healthcare provider at which this authorization was executed. Such revocation will be effective upon receipt, except to the extent that the recipient has already taken action in reliance on the Authorization. I am entitled to a copy of this authorization upon my request. I may not be required to sign this Authorization as a condition to obtaining treatment or payment or my eligibility for benefits. The recipient of this protected health information is prohibited from re-disclosing the information unless the recipient obtains another authorization from me or unless the discloser is specifically required or permitted by law. Where permitted, the information I am requesting to be disclosed may sometimes by redisclosed by the recipient and may no longer be protected by law. I am entitled to notice if my protected health information is used for marketing and results in remuneration to the provider. I hereby acknowledge that I have read and fully understand the above statements as they apply to me. Print Patient Name: Signature of Patient: Signature of Guardian: Relationship: D.O.B.: Date: Date: Witness:
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
More informationPatient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
More informationPlease complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
More informationAdult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
More informationPATIENT 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
More informationPatient Name: 1831 N. Belcher RD Suite C3 Clearwater, FL Phone: Fax: Authorization to Release Protected Information Da
Patient Name: 1831 N. Belcher RD Suite C3 Clearwater, FL 33765 Phone: 727-754-4959 Fax: 727-754-5910 Authorization to Release Protected Information Date of Birth: Instructions: Following section to be
More information- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
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
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Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
More informationOur office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.
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Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
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Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
More informationDate: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
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TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
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PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
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Dr. Mark Valente Dr. Andy Indresano Board Certified, Fellowship Trained Phone. 972.707.0005 Fax. 888.992.6199 DISCspine.com New Patient Intake Form Name First MI Last Street Address Apt # _ City _ State
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Medical History Record Today s For faster service, please complete the following form prior to arriving at our office. FIRST NAME: M.I. LAST NAME: Address City State Zip Code D.O.B. Sex: M F Email Home
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Medical Record # Patient Name(s) Date of Birth Social Security # Contact Phone # AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION OBTAIN FROM: (Releasing facility) RELEASE TO: (Receiving entity)
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NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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Today s Date: New Patient Registration and Medical History Patient Name: Nick Name: Address: Apt/Lot: City: State: Zip Code: Home Phone: Cell phone: Email: Is it ok to leave messages on the phone numbers
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Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
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PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
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Welcome to our office! We want to provide you with the very best in vision care. In order for us to serve you better, we need certain biographical information from you. Please complete the following data
More informationPatient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
Patient Registration Patient s Full Name: Home Address: Home Phone Number: Cell Phone Number: Social Security #: DOB: Relationship Status: Married Divorced Single Place of Employment: Work Address: Work
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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
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Thank you for choosing Community Hospital-Fairfax Family Medicine Clinics. We are delighted to provide your care. If you are a patient of the Rock Port, Tarkio or Fairfax Clinics, please complete this
More informationGARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:
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TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
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More informationAccompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
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Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
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Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
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FRIEDMAN & GREENHUT, DPM, PA PATIENT REGISTRATION FORM Patient Information Social Security # Date DOB First Name MI Last Address City, State, Zip Home # Cell # Male Female Email Single Married Widowed
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MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
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Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
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Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
More informationName: DOB: Sex: Male Female
Today s Date: Name: DOB: Sex: Male Female What doctor are you seeing today? Referring Physician s name and phone number: Primary Care Physician s name: Primary Care Physician s Phone Number: Reason for
More informationMailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
More informationo Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
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