Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:

Transcription

1 Patient s Last Name: First Name: Address: City: State Zip Phne: (Hme) (Wrk): (Cell): Age f Birth / / Occupatin Referred by: Patient s cnditin: Duratin f Prblem: Dctr: Dctr s Telephne: N. in husehld If Child: Parent r guardian: Parent 1 Occupatin: Parent 2 Occupatin: Siblings Emergency Cntact (ther than parent) (name & phne): Fees: New patient: Adult - $300, Child under 14 - $200 Fllw-up: Adult - $170, Child under 14 - $150 Office Plicies: 48-hurs (2 business days) cancellatin ntice Fr n-shws and late cancellatins, yu are charged half f treatment fee We d nt bill insurance directly We d nt take Medicare/Medical nr Wrkman s Cmp Payment is required at the time f yur visit. We accept cash, check r credit I have read and agree t hnr all ffice plicies. Signed

2 HEALTH QUESTIONNAIRE FAMILY HISTORY Did any bld relative suffer any f the fllwing? Please highlight and indicate which relative: Epilepsy Migraine Mental Illness Glaucma Diabetes Thyrid Hayfever Asthma Anemia Bleeds easily Osteprsis Arthritis Heart disease Hypertensin High chlesterl Alchlism Hepatitis Cancer HOSPITAL ADMISSIONS YEAR ILLNESS r OPERATION YEAR ILLNESS r OPERATION Medicatins/ Supplements ALLERGIES VACCINE TEST EXAM Tetanus/TD Rectal/Stl Flu Chlesterl Pneumnia Eye Exam Hepatitis TB Test Hepatatis MEDICAL HISTORY r Decreased hearing r Ringing in ear r Ear infectins r Dizzy r fainting spells r Failing visin r eye pain r Duble r blurred visin r Nse bleeds recurrent r Sinus truble r Sre thrats frequent r Harseness prlnged r Hayfever /Allergies r Pneumnia / Pleurisy r Brnchitis / Chrnic cugh r Asthma / Wheezing r Shrtness f breath rn exertin rlying flat r Chest pain r High bld pressure r Heart murmur rswllen ankles rirregular pulse rpalpitatins r Leg pain -when walking r Varicse veins / Phelebitis r Cld numb feet r Lss f appetite - recent r Difficulty swallwing r Heartburn rpeptic ulcer r Persistent Nausea / Vmiting r Abdminal Pain - chrnic r Gallbladder truble r Jaundice / Hepatitis r Diarrhea rcnstipatin r Diverticulsis rcrhn s / Clitis r Inflammatry Bwel Syndrme r Bldy r tarry stl r Hemrrhids rhernia r Urinatin / Overactive bladder rovernight mre than twice rmre than 8 times / 24 hrs rurgency t urinate rwith leakage r Decrease in frce/flw r painful r Stress incntinence urine leakage with exercise /mvement r Bld in urine rkidney stnes r Urine infectins frequent r Sexually transmitted diseases r Sexual prblems r Weight lss rgain recent r Anemia rbruise easily r Bld transfusins r Cancer rchrnic fatigue r Diabetes rthyrid disease r Seizures rstrke r Tremr / hands shaking r Numbness / tingling sensatins r Headaches frequent r Arthritis / Rheumatism r Back pain recurrent r Bne fracture / jint injury r Osteprsis r Ft pain rgut r Rashes rhives r Psriasis reczema r Any type f sleeping difficulty r Depressin rnervusness r Agitatin rmemry lss r Mdiness r Suicidal thughts r Phbias rmental illness r Feelings f wrthlessness r Rheumatic fever rscarlet fever r Chickenpx rpli rmumps r Measles rgerman measles r Tuberculsis rherpes r AIDS / HIV r Alchl z/week r Cffee / Tea cups per day r Smking cig/day # years year quit r Exercise r Street drugs r Acupuncture / tatts r Hair lss _ prgressive _ recent MALES: r Prstate prblems FEMALES Please cmplete: Menstrual Flw: rregular r Irregular r Pain/Cramps Days f flw Length f cycle f 1 st day f last perid rpain / Bleeding during r after sex Number f Pregnancies Abrtins Miscarriages Live Births Birth cntrl methd r Flushing / Menpause f last PAP test rnrmal rabnrmal f last mammgram rnrmal rabnrm

3 MEDICAL RELEASE FORM Tday's : Patient Name: Please print f Birth Permissin t release infrmatin t Insurance Carriers: I give permissin t this ffice t release medical infrmatin t my health r autmbile insurance cmpany. (Print Name f Patient/Guardian) Please cntact me when yu receive requests fr infrmatin frm my insurance carrier. 2. Permissin t Share Infrmatin with Health prviders: I give permissin t this ffice t share my medical infrmatin with my ther health prviders s that they may crdinate my care. (Print Name f Patient/Guardian) Please cntact me befre sharing any infrmatin with my ther health prviders.

4 HIPPA NOTICE OF PRIVACY PRACTICE - ACKNOWLEGEMENT OF RECEIPT I hereby acknwledge that a current cpy f the medical practice s Ntice f Privacy Practices is available nline at as well as in the receptin area. I further acknwledge that a cpy f any amended Ntice f Privacy Practices will be available at each appintment. Patient: (Print Name f Patient/Guardian) Address: If nt signed by the patient, please indicate relatinship: Parent r guardian f minr patient Guardian r cnservatr f an incmpetent patient

5 MEDICARE BENEFICIARY AGREEMENT I, Medicare beneficiary, clearly understand that by signing this cntract, I will: 1. Agree nt t submit a claim (fr such items r services, even if such items r services are therwise cvered by Medicare). 2. Agree t be respnsible, whether thrugh insurance r therwise, fr payment f such items r services, and understand that n reimbursement will be prvided fr such items r services by Medicare. 3. Acknwledge that n limits apply t amunts that may be charged fr such items r services. 4. Acknwledge that Medigap plans d nt, and ther supplemental plans may elect nt t make payments fr such items r services, because payment is nt made with Medicare. 5. Acknwledge that, as a Medicare beneficiary, I have the right t such items and services prvided by ther physicians r practitiners, fr whm payment wuld be made under Medicare. (Print Name f Patient/Guardian)