PATIENT REGISTRATION

Transcription

1 PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth: '/ Marital Status: Single / Married/ Separated / Divorced / Widowed Who referred you? Doctor's Name: Phone #: ( ) Social Security Number: ~ -'/ Drivers license #: State: Employer/ School: Occupation: Sex: Male or Female Home #: ( ) Cell #: ( ) Work #: ( ) Ext.: : Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Work #: ( ) Ext.: Primary Insurance Name: PPO/HMO/POS/INDEMINTY /other: Insured Name: Insured Social Security #:..J1 -'1 Date of birth of policy holder: ! ;..' Relationship: SELF I HUSBAND / OTHER: ID/Policy /Cert. #: Group/Account#: Secondary Insurance Name (if any): PPO/HMO/POS/INDEMINTY /other: Insured Name: Date of birth of policy holder: ~ ! Insured Social Security #:...JI --'/ Relationship: SELF / HUSBAND / OTHER : ID/Policy/Cert. #: Group/Account #: RESPONSIBLE PARTY (IF OTHER THAN PATIENT) : Name: Date of birth: ~ ! Relationship: Address: Apt #: City: State: Zip: Social Security #: ---' Employer Name: Occupation: Home #: ( ) Cell #: ( ) Work # : ( ) Ext.: MEDICAL CARE: I authorize Dr. Padma Horvit, M.D., P.A. or her designee to provide myself or my child with rea sonable and proper medical care according to today's standards. MEDICAL INFORMATION : I authorize Dr. Padma Horvit, M.D., P.A. staff and billing representative to release my information necessary to my or my child's in surance company(s), third party payor so that they may obtain payment for medical services rendered. INSURANCE AUTHORIZATION : I hereby authorize Dr. Padma Horvit, M.D., P.A. staff and billing representative to furnish information to my or my child's insurance company (s) concerning treatment rendered by Dr. Padma Horvit M.D., P.A. or her designee. ASSIGNMENT OF BENEFITS: I authorize the insurance company(s) or any third party payor to pay benefits directly to Dr. Padma Horvit, M.D., PA, should they accept assignment for such treatment. I ALSO AGREE THAT I AM FINANCIALY RESPONSIBLE FOR ALL CHARGES UNPAID BY MY INSURANCE COMPANY (5). Signature of Patient or Guarantor: Today's date: !

2 Padma K. Horvit, M.D., P.A. Endocrinology PATIENT QUESTIONAIRRE Pharmacy name and number: Do we have your permission to call you at work? Yes No -- Do you authorize Dr. Horvit or her staff to leave medically related information on your home or work answering machine? Yes No -- Patient's signature: Date:

3 PADMA K. HORVIT, M.D., P.A. ENDOCRINOLOGY HEALTH HISTORY Name: DOB: / / Sex: M F Ref~edBy: Check all items that apply to you and fill in blanks as needed Past Medical History: _ Allergies (other than drugs ), Anemia or blood problems Arthritis Asthma _ Cancer/Tumor, explain: Colon disease _ COPD, emphysema, lung disease _ Diabetes, type, how long Drug or alcohol abuse _ Epilepsy Glaucoma _ Headaches, type ~ _ Hearing loss Heart disease or heart attack _ Hepatitis ABC or jaundice _ Hypertension (high blood pressure) _ Hypothyroid or hyperthyroid _ Kidney disease or stone _ Mental illness or depression _ Pap smear, abnormal _ Peptic ulcer disease Stroke Tuberculosis (TB) Other: Past Surgical & Hospitalization History: _ Angioplasty or _ Heart Bypass _ Appendectomy _ Back, procedure: Breast, R or L, procedure: Cervical freezing or LEEP Fracture, Gallbladder _ Hernia, R or L, type: Hysterectomy (uterus) Ovaries removed _ Knee, R or L, procedure: Psychiatric treatment, inpatient or outpatient _ Tonsillectomy _ Tubal ligation (Tubes tied) _ Vasectomy Other: Other: ,

4 HEALTH HISTORY (cont'd) Females Only: Age at first period: ----yrs. old Birth control method: Number of: Pregnancies Live births Miscarriages Abortions Date of last: Period --- Pap smear Mammogram Males Only: Date of last: Physical exam Prostate exam --- PSA Drug Allergies: _No Known Drug Allergies Name of Drug Reaction Current Medications: (prescription, over-the-counter, herbs, vitamins) Medication StrengthIDose Frequency Medication StrengthIDose Frequency Social History: Marital Status: Married Divorced _ Single _Separated Widowed Occupation: Highest level of education: Tobacco: _Cigarettes Smokeless How muchlday: how long _ quit when Alcohol: Number of drinks per day or week _ Caffeine: Number of cups of coffee /day, glasses of tea ---'/day, sodas /day Do you exercise regularly? ~ Family History: Age Father Mother Father's father Father's mother Mother's father Mother's mother Brothers Sisters Children Living Health status or illness Deceased Cause of death & illnesses 2

5 HEALTH HISTORY (cont'd) LIST OF SYMPTOMS PLEASE CHECK ALL THOSE THAT APPLY Excessive weight gain lb. in months Excessive weight loss lb. in months Excessive sweating, hair change or hot/cold insensitivity Prolonged sore throat, hoarseness, or difficulty swallowing Shortness of breath Chronic cough Chest pain or irregular heart beat Abdominal pain, nausea, change in bowel habits or control Change in urination frequency, pain upon urinating, incontinence Change in menstrual cycle (Women) or impotence (Men) Change in hearing Change in sense of smell or taste Blurred vision Double vision Excessive tearing or itching of eyes Generalized weakness or fatigue (all muscles) Specific limb or muscle weakness - specify: Numbness - specify where: Muscle pain or tenderness - specify where: Swelling of the ankles Skin changes - specify: Bruise easily Memory loss Nervousness Change in appetite Difficulty concentrating Depression Sleeping too much - average sleep per night: Inability to sleep (Insomnia) - average sleep per night: hours hours 3

6 LIST OF SYMPTOMS (cont'd) Blackouts (fainting spells) Lightheaded - the feeling of almost passing out Vertigo - the feeling of the room or yourself spinning Headaches None of the above Other - specify: Patient's signature: Date: Physician'S signature: Date: