Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax:

Size: px
Start display at page:

Download "Josette E. Spotts, MD, FACS W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax:"

Transcription

1 Josette E. Spotts, MD, FACS 1485 W. Warm Springs Road, Suite 105 Henderson, NV Tel: Fax: Patient Name: Date: Age: Referred by: Reason for visit:

2 Patient Name: Medical History Please check if you have a history of any of the following: Congestive heart failure Heart attack Arrhythmia Mitral valve prolapse Hypertension Stroke High cholesterol Valvular disease COPD Emphysema Pulmonary embolism Sleep apnea Chronic bronchitis Kidney disease Kidney failure Chronic UTI Gastritis Chron s disease Peptic ulcer Hepatitis Irritable bowel syndrome GERD Hiatal hernia Anemia Blood clots Bleeding disorder Arthritis Fibromyalgia Diabetes Thyroid Disease Osteoporosis Osteopenia Parkinson s disease Seizure disorder Migraine headaches Multiple sclerosis Dementia Bipolar Cancer Surgical History Surgery Date Surgery Date 1) 4) 2) 5) 3) 6) Previous Blood Transfusions: Y N Did you have a reaction? Y N If yes, what was the reaction?

3 Please list drug allergies and reactions: 1) 3) 5) 2) 4) 6) Medications-Vitamins-Supplements Name: Dose: Name: Dose: Social History Are you currently: Employed Unemployed Retired Disabled Occupation: Circle One: Single Married Divorced Widowed Separated Have you ever smoked? Yes No Average pack per day: If yes, your age when you started? Date quit (if applicable): Do you drink alcohol? Yes No If yes, how much per week? Use of recreational drugs: Yes No If yes, what type? Heart disease High cholesterol High blood pressure Stroke Diabetes Bleeding disorders Blood clots Family History Please check all that apply Yes Relationship

4 Family Cancer History Family Member Type of Cancer Age Living Deceased OB/GYN History Age of first period: Date of last menstrual period: Are you currently pregnant? Yes No # of pregnancies # of live births Age of first pregnancy History of breast feeding? Age of first live birth Yes No History of hormone replacement therapy? History of birth control pills? Yes No Yes No If yes, how long were you on the following: Birth control pills Hormone replacement therapy Please check if you CURRENTLY have any of the following symptoms: Fatigue Weight change Insomnia Hot flashes Sinusitis Ringing in ears Visual changes Difficulty swallowing Hoarseness Sore throat Vomiting Heartburn Constipation Diarrhea Hemorrhoids Burning with urination Blood in urine Need to urinate at night Incontinence Vaginal discharge

5 Chest pain Palpitations Ankle swelling Cough Shortness of breath Wheezing Abdominal Pain Nausea Depression Vaginal dryness Irregular periods Painful periods Heavy periods Muscle pain Back pain Skin rash Anxiety

6 LIMITED ENGLISH PROFICIENCY OF LANGUAGE ASSISTANCE SERVICES FOR NEVADA ATTENTION: If you speak any of the following languages, language assistance services, free of charge, are available to you. Call for more information. Amharic: ትኩረት: እርስዎ የ አማርኛ ተናጋሪ ከሆኑ የቋንቋ ድጋፍ አገልግሎቶች ያለ ክፍያ በነጻ ተዘጋጅልዎታል:: በ ይደውሉ:: Arabic ملحوظة: إذا كنت تتحدث اللغة العربية تتوافر لك خدمة المساعدة اللغوية بالمجان. برجاء االتصال ب Chinese: 注意 : 如果您讲中文, 我们可以为您提供免费语言协助服务 请拨打 German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufen Sie Japanese: ご注意 : 日本語でお話しになりたい場合は 無料の言語支援サービスをご利用いただけます にお電話ください Russian: ВНИМАНИЕ: Если вы говорите по-русски, вам предложены бесплатные услуги перевода. Звоните по телефону Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llamar al Thai: โปรดทราบ: หากค ณพ ดภาษาไทย บร การให ความช วยเหล อด านภาษาพร อมให บร การแก ค ณโดยไม ม ค าใช จ าย โทร Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Hãy gọi French: ATTENTION : Si vous parlez français, des services d'aide linguistique, vous sont proposés gratuitement. Appelez le Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan iti Korean: 안내 : 한국어통역지원서비스를무료로 제공해드리고있습니다. 지원이필요하시면, 전화 로문의하시기바랍니다. Samoan: FAAALIGA: Afai e te tautala Faa-Samoa, o loo maua fesoasoani mo tautua tau gagana, e lē totogia mo oe. Telefoni i le Tagalog: ATENSYON: Kung nagsasalita ka ng Tagalog, ang mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit mo. Tumawag Urdu: توجه: اگر فارسی صحبت میکنید خدمات ترجمه به صورت رایگان در اختیارتان قرار میگیرد. با تماس بگیرید.

Family and Self Health History for Genetic Counseling. Your Personal Health History

Family and Self Health History for Genetic Counseling. Your Personal Health History Family and Self Health History for Genetic Counseling Your Personal Health History NAME: DATE OF BIRTH: 1. Your weight: (pounds) Your height: feet inches 2. Have you ever had cancer? YES NO If YES, please

More information

CCCN Patient Questionnaire

CCCN Patient Questionnaire CCCN Patient Questionnaire Date: Patient Name: Age: Referred by: Primary Care Physician: Please provide names and phone numbers of your physicians (primary care, medical oncologist, surgeon, etc.): Reason

More information

2019 Formulary Monthly Notice of Change

2019 Formulary Monthly Notice of Change Updated: 03/01/2019 2019 Formulary Monthly Notice of Change Medicare Advantage Employer Group Plans (EGWP) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete

More information

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina.

Summary of Benefits. Humana Walmart Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina. SBOSB026 2018 Summary of Benefits Humana Walmart Rx Plan (PDP) State of North Carolina Our service area includes the following state(s): North Carolina. Other pharmacies are available in our network. GNHH4HIEN_18

More information

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus

There are 2 kinds of appeals with Blue Cross of Idaho Care Plus You have the right to appeal our decision You have the right to ask Blue Cross of Idaho Care Plus to review our decision by asking us for an appeal. If you lose the Medicaid services appeal with Blue Cross

More information

Notice of Denial of Medical Coverage

Notice of Denial of Medical Coverage Important: This notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under Get help & more information.

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE LIVE HEALTHY ENJOY REWARDS GCHJMJXEN 0916 Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Health TALK. Mammograms save lives. Plan to quit.

Health TALK. Mammograms save lives. Plan to quit. Health TALK FALL 2018 Plan to quit. Every November, the Great American Smokeout asks everyone to quit smoking. You can quit for just that one day. Or it could be the fi rst day of a permanent, healthy

More information

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico*

2019 Over-the-Counter Drugs and Vitamins - Puerto Rico* 209 Over-the-Counter Drugs and Vitamins - Puerto Rico* Federal Employees Health Benefits Program Effective January, 209 OVER-THE COUNTER COVERAGE FOR PUERTO RICO CATEGORY PRODUCT LIMIT Allegra-D 2 Hour

More information

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916

Ready. Set. CAPTURE LIFE REWARDS. Earn plenty of Points. GET ACTIVE ENJOY LIVE HEALTHY REWARDS GCHJMJXEN 0916 Ready. Set. CAPTURE LIFE REWARDS Earn plenty of Points. GET ACTIVE GCHJMJXEN 0916 LIVE HEALTHY ENJOY REWARDS Say hello to Go365. It s your personalized wellness and rewards program. Getting healthier is

More information

Kadlec Regional Medical Center 0118 KMC-002B

Kadlec Regional Medical Center 0118 KMC-002B Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d Kadlec Regional Medical Center 0118 KMC-002B Washington ASO KMC-002B Kadlec HSA 10/25/50/3000 1500d n

More information

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK?

Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? Life After a Heart Attack WHAT ARE MY CHANCES OF HAVING ANOTHER HEART ATTACK? A previous heart attack increases your risk of having a second one. However, you can make changes to prevent a second heart

More information

Luana i ke ola maika i

Luana i ke ola maika i OCTOBER 2018 Luana i ke ola maika i Enjoying good health Tips for a lifetime of good health and well-being are here. IN THIS ISSUE: Open Enrollment: Stick With HMSA We re More than What You d Expect We

More information

Take Charge of YOUR COPD

Take Charge of YOUR COPD Take Charge of YOUR COPD You are the Key Did you know that Chronic Obstructive Pulmonary Disease (COPD) Flare-Ups cause your COPD to progress faster and shorten your life? The key is managing your COPD

More information

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC

Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC Sore Throat or Strep? ALWAYS GET A STREP TEST BEFORE TAKING AN ANTIBIOTIC What is Strep? Strep or strep throat is also known as Streptococcal Pharyngitis. Pharyngitis is a type of sore throat and is a

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS BASIC DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS (& CHILDREN AGE 19 THROUGH 25) PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person

More information

APPOINTMENT OF REPRESENTATIVE

APPOINTMENT OF REPRESENTATIVE PO Box 31368 Tampa, FL 33631-3368 APPOINTMENT OF REPRESENTATIVE Name: Member number: Reference/Case number: PART 1 --- APPOINTMENT OF REPRESENTATIVE (to be filled out by member) I allow (Name of person

More information

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language: Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred

More information

GCHJUV2EN Member Registration Guide

GCHJUV2EN Member Registration Guide GCHJUV2EN 0417 Member Registration Guide Go365 Trilogy Member Registration Instructions Two Ways to Register for Go365 1. Go365.com 2. Go365 App (available in the Apple and Google Play Stores) Select the

More information

DATE OF BIRTH: MELANOMA INTAKE

DATE OF BIRTH: MELANOMA INTAKE MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other

More information

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky

Affordable Care Act Section 1557 Nondiscrimination Policy for Kentucky 1. Nondiscrimination Notice and Accessibility Requirements. ENT & Allergy Specialists will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and

More information

Healthy. Now Men: Take Care of Your Health

Healthy. Now   Men: Take Care of Your Health Healthy SPRING 2018 Now www.amerihealthcaritasdc.com Men: Take Care of Your Health Here s a fact you may not know: Men are dying, on average, almost five years earlier than women. 1 This is largely because

More information

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.

More information

Getting to the BOTTOM OF BACK PAIN

Getting to the BOTTOM OF BACK PAIN Getting to the BOTTOM OF BACK PAIN What You Should Know About Low Back Pain Do I Need an X-ray? According to the American College of Physicians, most people with low back pain feel better after a month

More information

2019 Summary of Benefits Medicare Prescription Drug Plans. BlueMedicare Value Rx (PDP) S

2019 Summary of Benefits Medicare Prescription Drug Plans. BlueMedicare Value Rx (PDP) S 2019 Summary of Benefits Medicare Prescription Drug Plans BlueMedicare Value Rx (PDP) S5904-006 January 1, 2019 December 31, 2019 The plan s service area includes: State of Florida 1 Y0011_92839_M 0818

More information

Living with DIABETES

Living with DIABETES Living with DIABETES Mark Your Calendar Regular tests and screenings can ensure you re on the right track with your Diabetes. You should complete the following screenings at least once or twice a year:

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS DELUXE DENTAL PLAN Summary of Dental Benefits Effective January 1, 2019 ADULTS AGE 19 & OLDER PLAN MAXIMUM $1,000 per person, per calendar year. The most HDS will pay for each person for all covered

More information

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory

Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory Community Care Family Care Partnership Program (HMO SNP) (Community Care) 2019 Pharmacy Directory This pharmacy directory is updated monthly For more recent information or other questions, please contact

More information

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your

More information

Your Feelings Matter WITH TYPE 2 DIABETES

Your Feelings Matter WITH TYPE 2 DIABETES Your Feelings Matter WITH TYPE 2 DIABETES A new diagnosis of type 2 diabetes may trigger a range of emotions from minor stress to major depression. Recognizing and addressing emotional reactions can play

More information

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about.

Total Health Plus supplemental benefits designed for members in need of extra care. We re giving you more to smile about. HDS INDIVIDUAL DENTAL PLAN FOR CHILDREN Summary of Dental Benefits Effective January 1, 2019 CHILDREN BENEFIT ENDS AT AGE 26 MAXIMUM OUT OF POCKET (MOOP) $350 per child or $700 for 2 or more children,

More information

Healthy Moves. A better flu season for you

Healthy Moves. A better flu season for you Fall/Winter 2017 Healthy Moves A better flu season for you Adults 65 years of age and older are a higher risk for getting and developing serious risks from the flu. Some of the risks are bronchitis, sinus

More information

Member Matters Newsletter

Member Matters Newsletter Member Matters Newsletter 2017 Winter Issue IN THIS ISSUE 2 A New Year with Premier HealthOne 2 Is it Time to See Your Doctor? 3 Chicken & White Bean Soup 4-5 Preventive Health Checklist 6-7 Recognizing

More information

1 Some long-term drugs aren t available through mail order. Check our Formulary (List of Covered

1 Some long-term drugs aren t available through mail order. Check our Formulary (List of Covered CVS/caremark Mail Service Pharmacy Program: Molina Medicare Options Plus HMO SNP s Mail Order Prescription Service You re important to us at Molina Healthcare. So we d like to offer you a way to save time

More information

Preventive Health Care Guide Adults. Save and share with your doctor! Primary Care Office Visits. Screening Schedule. Immunization Schedule

Preventive Health Care Guide Adults. Save and share with your doctor! Primary Care Office Visits. Screening Schedule. Immunization Schedule Preventive Health Care Guide 2016 2017 At any stage of life, it s important to make your health a priority. That means making healthy lifestyle choices and seeing your doctor regularly. The charts on the

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:

More information

Welcome to About Women by Women

Welcome to About Women by Women Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have

More information

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy

More information

NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic

More information

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription

More information

Complete. Pennsylvania. How your plan works. Calendar year deductible This is the amount you will pay out-of-pocket for services in a calendar year

Complete. Pennsylvania. How your plan works. Calendar year deductible This is the amount you will pay out-of-pocket for services in a calendar year Complete Individual Dental Pennsylvania About your plan Good health starts with a healthy mouth. Regular dental exams and cleanings can lower the risk of gum disease, which is linked to heart disease,

More information

SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE

SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper

More information

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury

More information

Salt Lake Orthopaedic Clinic Initial Visit Form

Salt Lake Orthopaedic Clinic Initial Visit Form Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing

More information

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status

More information

Initial Consultation

Initial Consultation Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention

More information

UnityPoint Clinic - Cardiology

UnityPoint Clinic - Cardiology UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:

More information

Health Questionnaire

Health Questionnaire Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you

More information

New Patient Information

New Patient Information Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician

More information

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital

More information

Luana i ke ola maika i

Luana i ke ola maika i SEPTEMBER 2017 / VOLUME 14 / ISSUE 2 Luana i ke ola maika i Enjoying good health IN THIS ISSUE Mahalo, HMSA Members! Plus 3 Steps to a Better You Tell us What You Think Fun Family Fall Recipes HMSA QUEST

More information

Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:

Name(last, first): Home Phone: Cell Phone:  address: Date of birth: SSN: 36320 Inland Valley Drive Suite 201 Wildomar, CA 92595 Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: E-mail address: Date of birth: SSN: Would

More information

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children? PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:

More information

Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.

Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician. Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP

More information

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

PULMONARY MEDICINE PATIENT QUESTIONNAIRE PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical

More information

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you. Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information

More information

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth: Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression

More information

2018 Formulary Annual Notice of Change

2018 Formulary Annual Notice of Change Updated: October 1, 2017 2018 Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2018 MAPD formulary. For a complete list, please

More information

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work

More information

Healthy Moves. Top Five Tips for Aging Better. Summer 2017

Healthy Moves. Top Five Tips for Aging Better. Summer 2017 Summer 2017 Healthy Moves Top Five Tips for Aging Better Aging is a natural process. Although, you cannot stop the clock, you can make the process smoother. Here are five tips to help you age better: 1.

More information

New Patient Health Information

New Patient Health Information MEDICAL FACULTY ASSOCIATES DEPARTMENT OF GENERAL SURGERY DIVISION OF BARIATRIC SURGERY 1011 NEW HAMPSHIRE AVE, NW WASHINGTON, DC 20037 New Patient Health Information The information obtained from this

More information

2018 PHARMACY COVERAGE. Get the most from your pharmacy benefits. Classic Pharmacy Network with FlexRx Drug List

2018 PHARMACY COVERAGE. Get the most from your pharmacy benefits. Classic Pharmacy Network with FlexRx Drug List 2018 PHARMACY COVERAGE Get the most from your pharmacy benefits Classic Pharmacy Network with FlexRx Drug List Understanding your prescription coverage Take an important first step to getting the most

More information

Health History Intake Form;

Health History Intake Form; Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies

More information

RHEUMATOLOGY PATIENT HISTORY FORM

RHEUMATOLOGY PATIENT HISTORY FORM !! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant

More information

Patient Intake Form for Allegany Ear, Nose, & Throat

Patient Intake Form for Allegany Ear, Nose, & Throat Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?

More information

MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM

MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO

More information

Medical History Form

Medical History Form Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart

More information

Creve Coeur Family Medicine, LLC

Creve Coeur Family Medicine, LLC Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal

More information

Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and

Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and Appendix A to Part 92 Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law Radiologic Associates, PC complies

More information

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please

More information

PATIENT HISTORY FORM

PATIENT HISTORY FORM PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:

More information

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan. Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of

More information

Patient History Form

Patient History Form Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:

More information

The benefit of knowing

The benefit of knowing The benefit of knowing Genetic testing for familial hypercholesterolemia (FH) A patient support guide 2 Does high cholesterol run in your family? In some families, high cholesterol is caused by familial

More information

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure

More information

New Patient Medical History Form

New Patient Medical History Form New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring

More information

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile) Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)

More information

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months *542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only

More information

Medication Allergies

Medication Allergies **PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.

More information

New Patient Questionnaire

New Patient Questionnaire New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist

More information

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:

More information

Laser Vein Center Thomas Wright MD Page 1 of 4

Laser Vein Center Thomas Wright MD Page 1 of 4 Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber

More information

Modesto Gastroenterology Medical Corporation

Modesto Gastroenterology Medical Corporation Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298

More information

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please

More information

Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH)

Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH) Notice of Receipt of Appeal/Grievance Macomb County Community Mental Health (MCCMH) Important: Read this notice carefully. If you need help, you can call one of the numbers listed on the next page under

More information

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Alivia Acupuncture Clinic, LLC. Address. City State Zip.  . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced

More information

DIVISION OF CARDIOLOGY

DIVISION OF CARDIOLOGY Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:

More information

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications): Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage

More information

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to: Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:

More information

J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health

J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:

More information

One mission: you Dental Plans. for Groups. Policy Form Numbers: (11-09) (11-09) (09-12) (01-15) Form No.

One mission: you Dental Plans. for Groups. Policy Form Numbers: (11-09) (11-09) (09-12) (01-15) Form No. One mission: you 2017 Dental Plans for Groups Form No. 15-022 (10-16) Policy Form Numbers: 3-229 (11-09) 3-141 (11-09) 3-202 (09-12) 18-083 (01-15) B BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL

More information

Notice of Appeal Approval Macomb County Community Mental Health (MCCMH)

Notice of Appeal Approval Macomb County Community Mental Health (MCCMH) Notice of Appeal Approval Macomb County Community Mental Health (MCCMH) Important: This notice explains the results of your appeal. Read this notice carefully. If you need help, you can call one of the

More information

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip: 3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:

More information

Plan Certificate. Complementary Care Rider

Plan Certificate. Complementary Care Rider Plan Certificate Complementary Care Rider January 2019 F01 Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate

More information

Patient Interview Form

Patient Interview Form Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information

More information