The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

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Claribel George
5 years ago
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1 PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Emergency Contact: Emergency Phone: Primary Care MD: 2nd Physician Referring Physician: Marital Status: How did you hear Spouse (If appl) about us? Pharmacy: HIPAA Choices: Did you receive a copy of the HIPAA Notice? Yes No Allow Voice Msg? Yes No Allow Postal Mail? Yes No Who may we leave a message with? Allow ? Yes No Allow SMS (text message?) Yes No Allow Calls to Cell? Yes No Occupation: Employer: (Leave blank if inapplicable) Employer Address: City / Language: Need Interpreter: Yes: No: Race: Ethnicity: Seasonal Resident: Yes: No:

2 PATIENT INFORMATION (PLEASE PRINT) Primary Insurance Provider: (Please provide a copy of your card) Insurer: Subscriber: Plan Name: (If self - do not complete the following lines) Effective Date: Relationship: Policy Number: Date of Birth: Group Number: Soc. Sec. # Co Pay: Sex: Subscriber Subscriber Address: Employer: Address: Subscriber Tele# Secondary Insurance Provider: (Please provide a copy of your card) Insurer: Subscriber: Plan Name: (If self - do not complete the following lines) Effective Date: Relationship: Policy Number: Date of Birth: Group Number: Soc. Sec. # Co Pay: Sex: Subscriber Subscriber Address: Employer: Address: Subscriber Tele#

3 PATIENT INFORMATION (PLEASE PRINT) Medical Information Release and Assignment of Benefits: is hereby authorized to furnish information to insurance carriers concerning my illness and treatments, and to collect all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered or paid by insurance. I am also responsible for any Deductible, Copay, and/or Coinsurance at the time services are rendered. I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. I have the right to revoke this authorization at any time in writing. Patient Signature Date Parent or Guardian Signature Date

4 PATIENT HISTORY Patient Name: Patient is here for: Chief Complaint: Pain Inflammation Spider Veins Swelling Skin Rash or discoloration Reticular Veins Varicose Veins Bleeding Numbness or tingling in legs Ulceration Reddened/hard knot in vein Burning Restless Leg Syndrome Leg Cramps Heaviness Which Leg: Right Left Both How Long: Previous Treatments: Worse With: Sitting Walking Menstrual Cycle Standing Working Lying Down Beginning of Day End of Day Pregnancy Improved By: Elevation Compression Hose Fluid Pills Rest Tylenol/Motrin Equivalent Walking Beginning of Day End of Day Social History: Alcohol: Never Rare Occasional/Social Daily Smoking: Never Quit > 10 yrs Quit 1-10 yrs Quit < 1 yr Current Smoker

5 PATIENT HISTORY (continued) Past Surgeries: Coronary Atrtery Bypass Angioplasty / Stenting Peripheral Vascular Surgery Past Medical History: Coronary Artery Disease High Cholesterol High Blood Pressure Diabetes Peripheral Vascular Disease Varicose Veins Allergies: Please List: Family History: Coronary Artery Disease Details: High Cholesterol Details: High Blood Pressure Details: Diabetes Details: Current Medications: Please List:

6 PATIENT HISTORY (continued) Review of Systems: Please check all that apply. Skin: Cardiovascular: Neurological: Itching Chest Pain Headaches Hives Palpitations Dizziness Bruising Shortness of breath Numbness Bleeding when sleeping Falls when walking Tremors Eyes: Legs swelling Stroke / TIA's Vision changes or loss Cramps Loss of memory Double Vision Varicose veins Problems with gait Color changes Ears: Legs/feet Psychiatric: Hearing aids Depression Hearing loss Gastrointestinal: Anxiety Pain Vomitting Bipolar Discharge Constipation Ringing Diarrhea Endocrine: Infections Heartburn Increased thirst Blood in stool Increased urine Nose: Changes in stool Intolerance to heat Nosebleeds Difficulty / pain Intolerance to cold Discharge in swallowing Diabetes Infections Jaundice Hot flashes Pain Liver Disease Gallbladder Disease Allergy / Immune: Mouth/Throat: AIDS Cavities Genitourinary: Hepatitis B Dentures Urine frequency Hepatitis C Bleeding Gums Pain Sores / Lesions Bloody urine Musculoskeletal: Hoarseness Incontinence Weakness Paralysis Respiratory: Hematology / Lymphatic: Stiffness Cough Anemia Joint Pain Blood Sickle Cell Swelling Shortness of breath Hemophilia Arthritis Asthma Swollen Glands Gout Emphysema Night Sweats Tuberculosis Itching Neck: Pneumonia Bronchitis Goiter Pain Thyroid problems Patient Signature: Date:

Amarillo Surgical Group Doctor: Date:

Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status: