Patient Registration Form

Transcription

1 Patient Registration Form Patient's Last Name: Patient's First Name: MI: Address: City, State, Zip Code: Patient's Date of Birth: Patient's Social Security: Best Number to Contact: Secondary Number: Marital Status: ( ) Single ( ) Married ( ) Widow ( ) Other Patient's Sex: ( ) Male ( ) Female Drug Allergies: Patient's Employer: (leave blank if patient is a minor): Reason for visit: Name of referring Doctor & number: Name of Primary Insurance: Name of Policy Holder: Date of Birth: Social Security Number of Policy Holder: (if different from above) Name of Secondary Insurance: Name of Policy Holder: Date of Birth: All services rendered are charged to the patient. The patient is responsible for payment regardless of insurance coverage. Full payment is expected at the time of each visit. In all instances when the patient is covered by a health insurance company with whom this office is a participating provider, we will verify eligibility and benefits directly with your insurance company. When necessary, we are happy to discuss this information with you in any effort to justify the amount you will be expected to pay. However, it is ultimately the responsibility of your insurance company to provide the education on the benefits available to you. All copayments, coinsurance, and deductibles are due at the time services are rendered: I hereby authorize the provider of services to release medical information concerning my examination and/or treatment for insurance purposes and to receive direct payment for medical benefits payable to me for services rendered. I, the undersigned, have completed this registration form to the best of my knowledge. Also, I have read and fully understand the payment policy & authorization of payment outlined above. I understand that if I need letters or medical records for my personal use, I will get charged a fee according to the office policy. I understand that if I cancel my appointment with less than 24 hours in advance or no show to my appointment or the appointment of my dependents I'm responsible of covering the slot that was reserved and it will incur on a charge of $ Yo entiendo que si cancelo my cita con menos de 24 horas de anticipacion o no vengo a Ia cita o la cita de mis dependientes soy responsable de cubrir el espacio reservado y tendre que pagar la cantidad de $ Signature: Date: Address:

2 Past Medical History (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation (Irregular Heartbeat) Bone Marrow Transplantation BPH (Benign Prostate Hypertrophy) Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure HIV/AIDS High Cholesterol Hyperthyroidism (High) Hypothyroidism (Low) Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Other: Past Surgical History (please put an X by all that apply) Appendix Removed Bladder Removed Breast Biopsy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Mastectomy (Right, Left, Bilateral) Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Colon: Colostomy Gallbladder Removed Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA (stent placement) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Other Kidney Stone Removal Kidney Transplant Kidney Removed (Right, Left) Liver Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries Removed: Endometriosis Ovaries Removed: Ovarian Cancer Ovaries Removed: Ovarian Cyst Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate Biopsy Prostate Removed: Prostate Cancer TURP (Prostate Treatment) Rectum: APR Rectum: Low Anterior Resection Skin: Basal, Melanoma, Squamous Skin: Biopsy Spleen Removed Testicles Removed (Right, Left, Bilateral) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Hysterectomy: Cervical Cancer NONE

3 Skin Disease History (please put an X by all that apply) Acne Actinic Keratosis Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Other Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Do you wear Sunscreen? If yes, what SPF? Do you tan in a tanning salon? Yes No Yes No Do you have a family history of Melanoma? if yes, which relative(s)? Yes No Medications: (please enter all current medications) Allergies to Medications: (please enter, all current medications)

4 Social History (Please put an X by all that apply) Cigarette Smoking: Currently Smokes Has smoked in the past Never smoked Former Smoker Alcohol Use: Other EtOH- None EtOH- less than 1 drink per day EtOH -1-2 drinks per day EtOH -3 or more drinks per day Family Medical History: (Only first degree relatives) Preferred Language: Race: Ethnic Group: Preferred pharmacy Name: Phone#: City or Zip code: ALERTS: (please put an X by all that apply) Allergy to Adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heartbeat with epinephrine Are you pregnant or currently trying to get pregnant?

5 Name: Date: Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following Fever or Chills Night Sweats Symptom Yes No - Unintentional Weight Loss Nausea Vomiting Sore Throat Rash Oral Sores Genital Sores Vision Problems Immunosuppression Hay Fever Chest Pain Shortness of Breath New or Changing Moles, Swollen Glands Problems with Bleeding Problems with Healing Problems with Scarring Dry Eyes Dry Lips Dry Skin Joint Aches Muscle Weakness Nosebleeds

6 Bloody Stools Abdominal Pain Dizziness. Problems with Night Vision Blurry Vision Headaches Neck Stiffness Depression Suicidal Ideation Anxiety Bloody Urine *** Please save and completed form to