Patient Registration Form
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- Estella Allen
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1 Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip: Work Phone: ( ) Cell Phone: ( ) Referred by: Complete this section only if someone other than the patient is financially responsible. Responsible Party: Relationship to Patient: Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip: Work Phone: ( ) Cell Phone: ( ) Name of Spouse: Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip: Employer s Telephone: ( ) In case of emergency, contact: Relationship: Home Phone: ( ) Work Phone: ( ) How did you learn about Georgia Vascular Institute? Can we mail information to your home? Can we leave a message for you at home? Can we leave a message for you at work? Can we send to the address you provided? 1
2 Welcome to our practice. As a new patient, please fill out the information found below to the best of your ability. Name: Age: Date of Birth: You were referred by: Today s Date: The reason why you are here today: PAST MEDICAL HISTORY Check all that apply. Diabetes High Blood Pressure Cancer Stroke Heart Problem Heart Attack/MI Heart Failure/CHF High Cholesterol Arthritis/Gout Other: Kidney Disease Thyroid Disease Emphysema/COPD Bleeding Tendency Ulcer Aneurysm Blood Clot/DVT Seizures Osteoporosis PAST SURGICAL HISTORY Check all that apply and fill in the date (month and year). Heart bypass Aortic aneurysm Leg bypass R/L Brain aneurysm Vein surgery R/L Gallbladder Carotid surgery R/L Thyroid Angioplasty Gastric bypass Appendix Hernia repair Other: FAMILY MEDICAL HISTORY Cancer Diabetes Hypertension Heart problems Aneurysm Stroke Varicose veins Father Mother Sibling 2
3 SOCIAL HISTORY Alcohol Tobacco/Smoking Drugs Do you live alone? Currently working? If yes, how much If yes, packs/day If you quit, when If yes, type frequency If yes, type MEDICATIONS Please list all the medications you are currently taking and dosages (Use additional separate medication list sheet if needed) ALLERGIES REVIEW OF SYSTEMS Please check all that apply. Constitutional Fever Chills Weight loss Weight gain Fatigue Headaches Skin Ulcers Rash Itching Changes in color Breast lump Breast discharge lbs lbs Eyes Glasses or contacts Blurred vision Cataracts Glaucoma ENT Hearing loss Earache or drainage Sinus problems Nose bleeds Bleeding gums Swollen neck glands Difficulty swallowing 3
4 Cardiovascular Musculoskeletal Chest pain at rest Chest pain with exertion Palpitations Leg or ankle swelling Respiratory Joint pain Joint swelling Muscle pain/cramps Back pain Pain legs/calf Cold extremities Short of breath-rest Short of breath-walking Wheezing or asthma Chronic cough Gastrointestinal Neurologic Dizziness/lightheaded Numbness/tingling Tremors Weakness Nausea Vomiting Diarrhea Constipation Abdominal pain Blood in stools Psychiatric Memory loss/confusion Depression Anxiety Insomnia Genitourinary Endocrine Frequent urination Painful urination Blood in urine Incontinence Prostate problems Excessive thirst Heat/cold tolerance Hormone problems Hematologic/Immune Easy bruising/bleeding Slow to heal after cuts Anemia HIV/AIDS Hepatitis A,B,C Clotting disorder 4
5 Venous Health History Form Patient Name: Date of birth: Chief complaint: DIRECTIONS: Please answer the following questions. Provide estimates for date of occurrence. PAST MEDICAL HISTORY 1. Have you ever had vein stripping surgery? If yes, when and which leg? 2. Have you ever had vein injections? If yes, when and where on the leg? 3. Have you ever had a blood clot? If yes, which leg and when? 4. Have you ever had phlebitis? If yes, which leg and when? FAMILY HISTORY Does anyone in your family have (or used to have) varicose veins, spider veins, leg ulcers or swollen legs? Father Mother Brother(s) Sister(s) Other 1. Do you experience any of the following in your legs? Aching/Pain? Heaviness? Tiredness/Fatigue? Itching/Burning? Swollen ankles? Leg cramps? Restless legs? Throbbing? Other? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Rt Leg Rt Leg Rt Leg Rt Leg Rt Leg Rt Leg Rt Leg Rt Leg Lt Leg Lt Leg Lt Leg Lt Leg Lt Leg Lt Leg Lt Leg Lt Leg Both Legs Both Legs Both Legs Both Legs Both Legs Both Legs Both Legs Both Legs 2. Have your veins gotten worse in recent months? Describe: 3. Do you take any medication for pain? (i.e. Advil, Motrin) If yes, what medication do you take and how many times/mgs per day? 4. Do you elevate your legs to relieve discomfort? If yes, how long per day do you elevate and does it provide relief? 5
6 5. Do you exercise? If yes, what kind of exercise and how often? Venous Health History Form (cont.) 6. Do you wear prescription compression stockings? If yes, what type and gradient? How long have you worn them? If yes, what is the name of the physician who prescribed your compression stockings and when were they prescribed? 7. Do you wear light support hose (i.e. Sheer Energy)? If yes, do they provide relief? 8. Do you have any problem walking? If yes, describe how it interferes with your activities of daily living. Which activities? 9. What type of work do you do? How long do you stand (hours per day) at work? At home? Describe how symptoms are/ if interfering with your essential job function of your specific job function, which activities: 10. Have you ever had any test(s) done on your veins? If yes, when and what type of test and where on the leg? 11. Were you diagnosed with saphenous vein reflux? 12. Name of referring Physician and how long have you been under his or her care for treatment of this condition? Patient signature: Date: PATIENTS: PLEASE STOP HERE. THE PHYSICIAN MAY GO OVER ADDITIONAL QUESTIONS WITH YOU. 6
7 Medication List Patient Name: Date of birth: MEDICATION DOSAGE FREQUENCY PHARMACY: PHONE #: 7
8 Consent and Acknowledgment Form I consent to the use or disclosure of my protected health information by Georgia Vascular Institute to any person or organization for the purposes of carrying out treatment, obtaining payment, or conducting certain healthcare operations. I understand that further information regarding how Georgia Vascular Institute will use and disclose my information can be found in Georgia Vascular Institute s Notice of Privacy Practices. By signing below, I understand and acknowledge the following: I have read and understand this consent, and I have received Georgia Vascular Institute s Notice of Privacy Practices currently in effect. Print name of individual or personal representative Signature of individual or personal representative Date If signed by the individual s representative, describe the legal authority of the representative to act on behalf of the individual: Unable to obtain written consent and acknowledgement because: Individual refused Emergency treatment situation Individual not able to sign due to incompetence or other medical reason Other: Staff Signature Date 8
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