AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION

Transcription

1 Medical Record # Patient Name(s) Date of Birth Social Security # Contact Phone # AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION OBTAIN FROM: (Releasing facility) RELEASE TO: (Receiving entity) Name Address Name Address City State Zip City State Zip Phone Fax Phone Fax INFORMATION TO BE PHOTOCOPIED AND RELEASED (CHECK ALL THAT APPLY): Date of service range (month/year): From: To: Emergency Room Report Mental Health Treatment Genetic Information Discharge Summary Drug/Alcohol Treatment HIV/AIDS Information Operative Report Radiology Reports Radiology Images History and Physical Laboratory Reports Other: Clinic/Progress Notes Immunization Records THE PURPOSE FOR THIS RELEASE: Continuity of Medical Care Damage/Claim Information Personal Use Legal Other: AUTHORIZATION: I hereby give the releasing facility permission to disclose my individually identifiable health information as listed above. I understand that once this information is disclosed, it may no longer be protected. I understand that this authorization is voluntary, that further treatment can not be conditioned upon my signing this authorization. I acknowledge that incomplete forms can not be processed and THAT THERE MAY BE A COST TO COPY THE RECORDS. I understand that this consent expires 180 days from the date of my signature unless otherwise specified as follows: I understand that I can take back permission to release my medical records at any time, except to the extent that action has already been taken to comply with it. I understand that I must provide notice in writing if I choose to revoke this authorization before the date/event of expiration, and that the written revocation must be signed and dated with a date that is later than the date on this authorization. A copy, fax or scan of this form is to be considered as valid as the original. Signature of Patient or Authorized Representative Date of Signature Printed Name Relationship to Patient (if applicable) MRD12546 M/Q (Rev 01/11) DOD Page 1 of 1

2 Name:_ Date of Birth: MRN::_ New Patient Medical History Form REASON FOR TODAY S VISIT: _ PERSONAL GENITOURINARY HISTORY None Please circle any that apply: Kidney Cancer Kidney Stones Prostate Infections Prostate Cancer Ureter Stones Prostate Enlargement Bladder Cancer Bladder Stones Infertility Testicular Cancer Bladder Infections Kidney Failure Do you leak urine when you cough or exercise? No Yes if yes, pads per day? Do you leak urine when you feel an urge to urinate but cannot get to the bathroom in time? Do you have problems achieving or maintaining an erection? PAST MEDICAL HISTORY: Have you ever had any of the following conditions? (Circle if yes) Anemia Arthritis Crohn s Disease Depression/Anxiety HIV/ AIDS Hypertension Asthma Diabetes Peptic Ulcer Disease Cancer, type: Kidney Disease Seizures COPD/Emphysema Endocrine Problems Stroke Myocardial Infarction GERD Ulcerative Colitis Clotting Disorder Glaucoma OTHER: Congestive Heart Failure Hepatitis PAST SURGICAL HISTORY: Have you ever had any of the following surgeries? (Circle if yes and provide date of surgery) DATE DATE DATE Adrenal Gland Surgery Colon Surgery Kidney Surgery Appendectomy Coronary Artery Bypass Graft Neck Surgery Bariatric Surgery Esophagus Surgery Prostate Surgery Bladder Surgery Gastric Bypass Surgery Small Intestine Surgery Breast Surgery Hemorrhoid Surgery Spine Surgery Cesarean Section Hernia Repair Stomach Surgery Cholecystectomy Hysterectomy Thyroid Surgery Other surgeries with dates: SOCIAL HISTORY: Alcohol use - Never Occasionally Daily Type Tobacco use - Never Previously, but quit Currently Packs Per Day for years Drugs use - Never Occasionally Daily Type What is your occupation? Marital Status: Single, Married, Divorced, Widowed, Separated, Other Children: Number of Children Number of grandchildren Women: # pregnancies, # deliveries - Vaginal, C-sections, Miscarriages

3 Name:_ Date of Birth: MRN::_ Medications: List more on a separate page if necessary. Medication Dosage / Frequency Dosage/Frequency Medication Dosage/Frequency 1) 6) 2) 7) 3) 8) 4) 9) 5) 10) Preferred Pharmacy: _ City: Cross Streets: Allergies: (No Yes) Circle if yes: Penicillin, Ampicillin, Sulfa Drugs, Bactrim, Macrodantin, Levaquin, Tape, Iodine, Latex, Other: Family History: Has anyone in your family had any of the following conditions? (Check if yes, and indicate relationship to you) Medical Condition Mother Father Sibling Grandmother Grandfather Other Relative Anesthesia Problem Kidney/Bladder/Prostate Cancer Bleeding Problems Heart Disease Kidney disease/stones Asthma/Breathing problems Diabetes Other: REVIEW OF SYSTEMS: (Please circle all that apply) CONSTITUTIONAL RESPIRATORY CARDIOVASCULAR BLOOD/IMMUNE ENT/EYES Appetite change Chills Fever Fatigue Weight Change Sweating Apnea Tightness Choking Cough Shortness of breath Chest pain Leg Swelling Palpitations Blood clotting Easily bruise Swollen nodes Neck pain Ear pain Congestion Visual Disturbances GASTROINTESTINAL NEUROLOGIC MUSCULOSKELETAL SKIN PSYCHOLOGIC Abdominal pain Constipation Diarrhea Nausea Vomiting Dizziness Light-Headedness Seizures Numbness/Tingle Back pain Joint pain Joint swelling Muscle pain Rash Color Change Wound Confusion Nervous/Anxious Agitation OTHER SYMPTOMS: Date: Patient Signature

4 Name: DOB: DOV: SHIM Score PATIENT INSTRUCTIONS: Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question. OVER THE PAST 6 MONTHS: 1. How do you rate your confidence that you could get and keep an erection? Very low Low Moderate High Very high When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? No sexual activity or none or 3. During sexual, how often were you able to maintain your erection after you had penetrated (entered) your partner? or none or 4. During sexual how was it to maintain your erection to completion of? Extremely Very Difficult Slightly 5. When you attempted sexual, how often was it satisfactory for you? or never Not or SCORE: Add the numbers corresponding to questions 1-5. If your score is 21 or less, you may want to speak to your doctor.

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