HUMANA PRACTITIONER ASSESSMENT FORM
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1 Patient Name: Patient ID: HUMANA PRACTITIONER ASSESSMENT FORM Physician Name: Provider ID: Date of Birth: / / Sex: Male Date of Service: / / month day year Female month day year Race/ethnicity: Hispanic/Latino American Indian Alaska Native Black/African American African Amputation Asthma/Allergies Asian Indian Asian Native Hawaiian Pacific Islander White/Caucasian : Condition X Medical History Medical Auto-Immune Disease Bleeding Disorders Cancer Cardiac Arrhythmias/Pacemaker Cataracts/Glaucoma COPD/Emphysema/Bronchitis CVA/TIA Diabetes GI Disease Heart disease (CHF, CAD, MI) Hypertension Hyperlipidemia/hypercholesterolemia Infectious Diseases Kidney disease Musculoskeletal disease Obesity Osteoarthritis Ostomies/Artificial Openings Paralysis Psychological/Emotional disorders Rheumatoid Arthritis Seizures/Convulsions/Epilepsy Serious injury/accidents Sinus disorders Sleep disorders Thyroid disease Vascular Disease Social Alcohol/Drug Use Tobacco Use Diet/Physical Activity Sexual History High Risk Lifestyle 1
2 Family History Mother Father Child Sibling Grandparent Cancer Diabetes Heart Disease Hypertension Surgeries Date Allergies: Medication Dosage Medication Dosage Preventive Services Date Test Completed Findings/Recommendations (Please indicate servicing provider if different from your practice) Annual Monitoring Persistent Medications (ACE/ARB, digoxin, diuretics, anticonvulsants) Serum potassium Serum creatinine Blood urea nitrogen Drug serum concentration Bone Mass Measurement Cardiovascular Disease Screening LDL Cholesterol and Result Colorectal Cancer Screening: Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Diabetes Screening & Management HbA1c and Result Dilated Retinal Exam Glaucoma Screening PAP and Pelvic Examination Prostate Cancer Screening Screening Mammogram Spirometry Testing 2
3 Immunizations: Influenza Pneumococcal Hepatitis B Tetanus Assessments/ Counseling Date Received Findings/Recommendations Pain Screening Functional Status Assessment (e.g. ADLs) Fall Risk Assessment Physical Activity Urinary Incontinence Medication Review ASA Use Discussion Advance Directive (Living Will Yes/No) Patient Name: B/P Height Weight WNL Physical Examination Received Abnormal Findings Appearance HEENT Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurological Psychiatric Hematologic/lymphatic/immuno 3
4 Diagnoses: X Artificial Openings Code Colostomy V44.3 Cystostomy V44.5 Gastrostomy V44.1 Ileostomy V44.2 Tracheostomy V44.0 X Circulatory System/Cardiac Code Angina pectoris, NOS Abdominal aortic aneurysm w/o Atrial fibrillation Bradycardia Cardiomegaly Cardiomyopathy (other primary) Coronary atherosclerosis w/o Chronic ischemic heart disease, Congestive heart failure, Deep vein thrombosis, NOS Heart valve, artificial V43.3 Hypertension, unspecified History of CVA V12.54 Late effect of CVA (note the late 438.xx Myocardial infarction, old 412 Pacemaker, cardiac V45.01 Peripheral vascular disease, nd Phlebitis, deep, lower extremity, Tachycardia Transient ischemic attack, unspec Venous insufficiency, unspecified X Digestive System Code Chronic hepatitis, unspecified Cirrhosis of liver (alcoholic) Cirrhosis of liver without mention of alcohol Constipation, unspecified Crohn s disease, unspecified Diverticulitis of colon, NOS Diverticulosis of colon, NOS Dyspepsia Esophagitis, unspecified Gastroenteritis and colitis Gastroesophageal reflux Hematemesis Hernia, hiatal, noncongenital Hernia, inguinal, NOS Peptic ulcer disease, unspec Ulcerative colitis, unspecified X Endocrine, Nutritional Disorders Code Diabetes Mellitus w/o 250.0x complications DM with Renal Manifestation 250.4x - Chronic Kidney Disease 585.x - Nephropathy, NOS DM with Ophthalmic Manifestation 250.5x - Retinopathy, background Retinopathy, proliferative DM with Neurological 250.6x Manifestation - Gastroparesis Peripheral autonomic Polyneuropathy DM with Peripheral Circulatory 250.7x Disord. - Gangrene Peripheral angiopathy X Endocrine (cont) Code DM with Specified Manifestation 250.8x - Ulcer (skin) note site 707.xx Glucose intolerance Hyperlipidemia, NOS Hypothyroidism, NOS Malnutrition (calorie) Obesity, unspecified Morbid Obesity X Genitourinary Code Benign Prostatic Hypertrophy Calculus of kidney / ureter 592 Chronic kidney disease,stage x Chronic kidney disease, unspecified Erectile dysfunction (not 2 nd to DM) Urinary tract infection End Stage Renal Disease Renal failure, unspecified 586 Hematuria, unspecified Renal dialysis status - A-V shunt or peritoneal V45.11 Noncompliance with renal dialysis V45.12 X Mental Disorders Code Alcohol abuse, unspecified Alcohol dependence, unspecified Alzheimer s disease Anxiety state, unspecified Bipolar disorder, NOS Dementia, senile, NOS Depressive disorder, NOS 311 Depression with anxiety Drug abuse, unspecified Drug dependence, unspecified Major depressive disorder, single, unspecified Schizophrenia, NOS Tobacco use disorder, unspecified X Musculoskeletal Code Amputation status, lower limb, unspecified level V49.70 Arthropathy, unspecified Arthralgia, site unspecified Back pain, unspecified Fracture, arm (closed) Fracture, leg (closed) Fracture, vertebra - traumatic, w/o mention of spinal cord injury 805 Fracture, vertebra - nontraumatic, osteoporotic, pathologic Fracture, other Low back pain Myalgia, unspecified Osteoarthrosis, unspecified Osteoporosis, unspecified Pain in limb Polymyalgia rheumatica 725 Prosthetic joint replacement V43.6 Rheumatoid arthritis Systemic lupus erythematosus
5 X Neoplasm Active Condition Code Malignant - Bladder, unspecified Bone, unspecified Breast, female, unspecified Cervix, unspecified Colon, unspecified Hodgkin s disease, NOS Leukemia, unspec w/o remission Lung, unspecified Prostate, primary Skin melanoma, site unspecified Skin, primary, site unspecified Uterine, unspecified primary: Benign - Colon Lipoma, unspecified site Unspecified site Metastatic note site /use code X Nervous System & Sense Organs Code Need a category - Bell s palsy Carpal tunnel syndrome Epilepsy, unspecified/seizure Hemiplegia and hemiparesis, Migraine, unspec, not intractable Multiple sclerosis Paraplegia of lower extremities Parkinsonism, primary Peripheral neuropathy, Seizure, NOS Sleep apnea, obstructive Tremor, essential/familial Eye Diseases - Cataract,senile,unspec(not 2 nd to Conjunctivitis, unspecified Glaucoma, unspec (not 2 nd to Visual loss, unspecified Ear Diseases - Cerumen impaction Hearing loss Otitis media, acute Vertigo, central COPD, NOS 496 Emphysema, NOS Obstructive chronic bronchitis with acute exacerbation Obstructive chronic bronchitis without exacerbation Pharyngitis, acute 462 Pneumonia, organism unspecified 486 Rhinitis, allergic, cause unspecified Shortness of breath X Respiratory (cont) Code Sinusitis, acute, NOS Sinusitis, chronic, NOS Upper respiratory infection, acute, unspecified site X Transplants Code Heart V42.1 Kidney V42.0 Liver V42.7 Lung V42.6 X Unlisted Diagnosis Code X Code Abdominal pain, unspecified Anemia, unspecified Aplastic anemia, unspecified Chest pain, unspecified Dysphagia, unspecified Epistaxis Gangrene Herpes simplex, any site Herpes zoster, NOS HIV disease 042 HIV positive, asymptomatic V08 Malaise and fatigue Nausea with vomiting Psoriasis, NOS Ulcer, chronic, unspecified site X Respiratory System Code Asthma, unspecified Bronchitis, acute Bronchitis, chronic, unspecified Chronic obstructive asthma, unspec
6 Assessment: Plan: Follow Up Appt. Notice to Physician: Medicare payment to Medicare Advantage Organizations is based in part on each patient's diagnoses, as attested to by the patient's attending physician by virtue of his or her signature on this medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. To the best of my knowledge, information, and belief, the information provided regarding diagnoses is truthful and accurate. Physician Name and Credentials (please print) Physician Signature and Credentials 6
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I Certain infectious and parasitic diseases 1 Tuberculosis A15-A19 X X Z 2 Sexually transmitted diseases (STD) A50-A64 Y Z 3 Viral hepatitis (incl. hepatitis B) B15-B19 X Z 4 Human immunodeficiency virus
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
Patient Intake Form for Allegany Ear, Nose, & Throat
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Patient Interview Form
Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
FROST FAMILY MEDICINE
Patient Information (Please Sign and return to Receptionist) Home Phone Day Phone Cell Phone E-mail Driver s License # Preferred Language Race Soc Sec # Gender: Male Female Marital Status: Single Married
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
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
DEMOGRAPHICS. Female Weight: lbs
DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage
NEW PATIENT INFORMATION RECORD PATIENT INFORMATION
Zumbro Vein Institute NEW PATIENT INFORMATION RECORD PATIENT INFORMATION 501 Blackburn Drive Martinez, GA 30907 706-854-8340 Fax: 706-854-8341 www.veinsaugusta.com First Name: Last Name: MI: Social Security
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
GENERAL INFORMATION Last Name: First Name: What name do you prefer to be called? Age: DOB: / / Height: Weight: Left or Right Handed : Right Left Marital Status: M S D W Name of spouse or significant other:
PATIENT INFORMATION (Please print all information) Date:
320 Lillington Ave Suite 101 Charlotte, NC 28204-3189 Phone: 704.362.4403 Fax: 704.362.4405 Please fill out the following form completely so that we may obtain the necessary information for our files and