3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
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1 3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier: DOB & Age: Race: Ethnicity: Hispanic Non-Hispanic Sex: SSN: Address: Employer Name: Occupation: Work Phone: Primary Care Physician: How did you hear about our clinic? Dr. Referral: Patient Referral: Friend: Google : Preferred Pharmacy: What is the nature of your visit? Emergency Contact Name: Relationship: Spouse Parent/Guardian : Home Phone: Cell Phone: Work Phone: Primary Insurance Name: Policy #: Group ID: Address: City: State: Zip: Policy Holder's Date of Birth: - Page 1 of 5 -
2 Secondary Insurance Name: Policy #: Group ID: Policy Holder's Date of Birth: Section I: Surgery and Anesthesia History 1. Have you ever had surgery? No Yes, please describe: 2. Have you or any of your blood relative had anesthesia complications of any kind? No Yes, please describe: Section II: Specific Medical History Height: Weight: lbs Are you pregnant? No Yes N/A Have you, or do you still have: No Yes Description 1. Asthma 2. Emphysema 3. High Blood Pressure 4. Heart Trouble (stents, heart attack, arrhythmia) 5. Hepatitis or Liver Trouble 6. Kidney Trouble 7. Diabetes 8. Epilepsy or Seizures 9. Stroke 10. Problem Scarring 11. Have you been advised to or had psychiatric care? 12. s Not Listed: - Page 2 of 5 -
3 Section III: Social History Do you smoke? 1. No, never No, but former smoker, quit Yes, current smoker, how much? 2. Do you drink? No Yes, how much? 3. Do you have children? No Yes, how many? years, days, months ago Section IV: Family History Have any blood relatives had any of the following? No Yes Description 1. Cancer 2. Bleeding Tendency 3. Leukemia 4. Heart Disease 5. High Blood Pressure 6. Repeated Infections 7. Chronic Lung Disease 8. Tuberculosis 9. Asthma 10. Severe Allergies 11. Kidney Disease 12. Arthritis 13. Mental Illness 14. Convulsions or Fits 15. Migraine Headaches 16. Diabetes 17. Gout 18. Thyroid Trouble 19. Obesity Section V: Medications Are you taking any medications, vitamins or herbal supplements? No Yes, please list: Section VI: Allergies and Sensitivities Are you allergic to any medications or local anesthesia? No Yes, please list: - Page 3 of 5 -
4 Section VII: Review of Systems In the past six months, have you experienced any of the following? If yes please note how and/or who is treating you for this. Constitutional Yes No Comments Gastrointestinal Yes No Comments Chills Vomiting Sweating Nausea Fatigue Liver problems Fever Heart burn/indigestion Lethargy Abdominal pain Sleep difficulties Constipation Weight loss Diarrhea Weight gain Jaundice Dark/tarry stools Eyes Blindness GU/Nephrology Cataracts Recurrent UTI Diabetic retinopathy No/low urine Glaucoma Blood in urine Glasses/Contacts Trouble with Urination Blurred Vision Pregnancy N/A Male Dry Eyes Dermatologic Ears/Nose/Throat/Neck Rash Hearing aids Skin Lesions Sore throat Stretch marks Frequent nose bleeds Nasal congestion Neurologic Dental pain Numbness/tingling Bleeding gums Abnormal walk Dentures/partials Speech trouble/aphasia Difficulty swallowing Frequent Headaches Seizure Cardiovascular Passing out Heart murmur Dizziness Chest pain/pressure Palpitations Hematologic/Lymphatic Bleed/bruise easily Respiratory Blood transfusion(s) Use Oxygen/BiPap/CPap Anemia Productive sputum Blood clots in veins Chest congestion Cough Psychiatric Cough up blood Depression Shortness of breath Anxiety Snoring Wheezing Musckuloskeletal Joint stiffness Joint swelling Muscle weakness Back pain I have read this questionnaire and disclosed my medical history to the best of my knowledge. Patient Signature: Date: - Page 4 of 5 -
5 Consent to Communicate Patient Name: Please mark the ways that you consent to us communicating with you: Method Ok to Leave Voic Ok to Leave Message with Another Person Call Work Phone Yes No Yes No Call Cell Phone Yes No Yes No Call Home Phone Yes No Yes No Preferred Contact Method(s) Best Time to Call* Send Appt Reminders Medical Info Marketing Info Send Regular Mail Mail to which Address: Home (please list): Send Text Page Text Appt Reminders if so, list cell carrier: Text Marketing Info if so, list cell carrier: *Best Time to Call Examples: morning, afternoon, daytime, evening, emergency only, do not call, or do not leave a message If it s ok to leave a message with another person, please list them: Name DOB Relationship OK to Release Results Yes No Any Comments Yes No Signature: Date: - Page 5 of 5 -
New Patient Information & Consents
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PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
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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: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
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Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
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:
Patient Label (Office Use)
Name: Patient Label (Office Use) VVMC Diversified Services Health History Survey And Contact Information Please provide the following information so we may contact you as needed. We may contact you to
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
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
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced