RIGGS Community Health Center 1716 Hartford St. Lafayette, IN (765)
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1 RIGGS Community Health Center 1716 Hartford St. Lafayette, IN (765) This section for office use. New patient Established patient Abstractor: : / / Patient Information Last Name First Name Middle Initial Address Home Phone Work Phone Cell Phone Address Marital Status Social Security Number: - - of Birth: / / Sex: Male Female Emergency Contact Last Name First Name Middle Initial Address Home Phone Work Phone Cell Phone Address Relationship Insurance What is the name of your insurance provider: Medicare Medicaid BC/BS Other (Please Specify): Effective : / / / Name of policy holder: Last Name First Name Middle Initial Relationship to Patient Address of policy holder if not the same as Patient s Phone: ( ) - Social Security Number of Policy Holder: - - Insurance Identification Number: Group Identification Number: Employment Status: Retired Full-Time Part-Time Unemployed Other: / Name of Employer (Company Name) Occupation Phone Number: ( ) - Address
2 Advance Directives Reviewed: None DNR Living Will Durable Power of Attorney HC Proxy Medications List all medications you take, prescription and nonprescription, and their dosage: Medication Dose No medications Medication Allergies Please check if you are allergic to any of the following medications or foods: Medication Reaction Medication Reaction Aspirin Lipitor (Atorvastatin Calcium) Accupril (Quinapril) Lodine (Etodolac) Accutane (Isotretinoin) Lopressor (Metoprolol) Adderall (Amphetamine salts) Loversol (Contrast media) Advil, Motrin (Ibuprofen) Maxipime (Cefepime) Albuterol Micronase (Glyburide) Altace (Ramipril) Minocin (Minocycline) Amaryl (Glimepiride) Morphine Atenolol (Tenormin) Naprosyn (Naproxen) Augmentin (Amoxicillin) Neomycin Bactrim (Sulfamethoxazole) Neptazane (Methazolamide) Bactrim Nicobid (Niacin) (Trimethoprim/Sulfamethoxazole) Omnicef (Cefdinir) Benadryl (Diphenhydramine) Omnipen (Ampicillin) Biaxin (Clarithromycin) Oxycodone Buspar (Buspirone) Pen-Vee K (Penicillin) Carafate (Sucralfate) Pepcid (Famotidine) Catapres (Clonidine) Percocet (Oxycodone) Ceclor (Cefaclor) Persantine (Dipyridamole) Cefazolin (Ancef) Plavix (Clopidogrel bisulfate) Cefizox (Ceftizoxime) Polymyxin B Cefzil (Cefprozil) Pravachol (Pravastatin sodium) Celebrex (Celecoxib) Prevacid (Lansoprazole) Cephalosporins Prilosec (Omeprazole) Cipro (Ciprofloxacin) Prinivil (Lisinopril) Clinoril (Sulindac) Prozac (Fluoxetine) Clozaril (Clozapine) Quinolones Codeine Ranitidine Conray (Contrast media) Risperidal (Risperidone) Cortisporin (Otic) Ritalin (Methylphenidate) Coumadin (Warfarin sodium) Septra (Sulfamethoxazole) Darvon (Propoxyphene) Singulair (Montelukast) DDAVP (Desmopressin) Spectracef (Cefditoren) Debrox (Carbamide peroxide) Strattera (Atomoxetine) Demerol (Meperidine) Sulfa Depakote (Valproic acid) Sulfonamides Dexedrine (Dextroamphetamine) Tagamet (Cimetidine) Diabeta (Glyburide) Tegretol (Carbamazepine) Diamox (Acetazolamide) Tetanus toxoid Diflucan (Fluconazole) Tetracycline Dilantin (Phenytoin Na) Ticlid (Ticlopidine HCL)
3 Medication Allergies Continued Medication Reaction Medication Reaction Duricef (Cefadroxil) Tofranil (Imipramine) Dynapen (Dicloxacillin) Tylenol (Acetaminophen) Erythromycin Valium (Diazepam) Flagyl (Metronidazole) Vancomycin Floxin (Ofloxacin) Vasotec (Enalapril maleate) Glipizide (Glucotrol) Vibramycin (Doxycycline) Haldol (Haloperidol) Wellbutrin (Bupropion HCL) Heparin Xopenex (Levalbuterol HCL) Inderal (Propranolol) Xylocaine (Lidocaine) Indocin (Indomethacin) Zestril (Lisinopril) Insulin Zithromax (Azithromycin) Insulin (Animal) Zocor (Simvastatin) Keflex (Cephalexin) Zovirax (Acyclovir) Klonopin (Clonazepam) Zyloprim (Allopurinol) Lasix (Furosemide) Other: Latex Other: Levaquin (Levofloxacin) Other: Food Allergies Food Reaction Food Reaction Food Reaction Chocolate Peanuts Strawberries Corn Red dye Wheat Eggs Rice Other: Iodine or Soy Other: shellfish Past Medical History Please indicate if you have ever experienced any of the following conditions. Please include the date of experience. Alcohol dependence / / Diabetes Type I / / Hepatitis / / Allergies / / Diabetes Type II / / Kidney stones / / Anemia / / Diarrhea / / Other kidney disease / / Angina / / Disc degeneration / / Anxiety / / Duodenal ulcer / / s Liver disease / / Arthritis / / Emphysema / / Low blood pressure / / Asthma / / Esophageal reflux / / Migraines / / Blood clots / / Gallbladder stones / / Mixed hyperlipidemia / / Broken bones / / Goiter / / Obesity / / Cancer / / Gout / / Osteoarthritis / / Type: Headache / / Osteoporosis / / Chronic blood thinner use / / Heart attack / / Palpatations / / Chronic bronchitis / / Heart disease / / Palpatations / / Chronic fatigue syndrome / / Other heart disease / / Rheumatoid Arthritis / / Chronic hepatitis / / Sciatica / / Chronic kidney disease / / Heart failure / / Seizures/epilepsy / / Chronic neck pain / / Hepatitis / / Sleep apnea / / Chronic sinusitis / / High blood pressure / / Stomach ulcer / / Circulatory disease / / High cholesterol / / Stroke (CVA) / / Colitis / / Irregular heart rhythm / / Thyroid disease / / Congestive heart failure / / Hypertension / / Tinnitus / / COPD / / Hyperthyroidism / / Tuberculosis / / Crohn s disease / / Insomnia / / Other: / / Depression / / Irritable bowel syndrome / /
4 Surgical History Please check all that apply. Angioplasty Cholecystectomy Liver biopsy Angioplasty w/ stent Colectomy Open Reduction Appendectomy Colostomy Internal Fixation Arthroscopy knee Gastric bypass Pacemaker Back surgery Hernia repair Small bowel resection Coronary Artery Bypass Graft Hip replacement Thyroidectomy Carpal tunnel release Knee replacement Tonsillectomy Cataract extraction LASIK Other: Female Surgical History Augmentation mammoplasty Mastectomy Bilateral tubal ligation Myomectomy Breast biopsy Reduction mammoplasty Cesarean section TAH/BSO (Total Abdominal Hysterectomy) / D and C (Dilation and curettage) (Bilateral Salpingo-Oophorectomy) Hysterectomy Vaginal hysterectomy Other: Male Surgical History Prostate biopsy Vasectomy TURP (Trans-Urethral Resection of the Prostate) Other: Family History Please check if any family member has had any of the following conditions and indicate the name of the affected member, the age of onset and/or if it was the cause of death. Adopted ADD/ADHD Alcoholism Allergies Alzheimer s disease Asthma Blood disease Heart disease Heart disease before age 50 Cancer Type: Depression Developmental delay Diabetes Eczema Hearing deficiency High cholesterol Hypertension Inflammatory Bowel Disease Kidney disease Learning disability Mental illness Migraines Obesity Osteoporosis Peripheral Vascular Disease Seizures/epilepsy Stroke (CVA) Other: Other: Mother Father Sibling(s) Grandparents Children Cause of Death
5 Social History Do you use tobacco? Yes No Former Type of tobacco used? / Packs per day? Years smoked? Year Quit? Other Tobacco units per day (cans, cigars, etc)? Units per day? Years used? Year Quit? Do you drink caffeine? Yes No Type? Amount Daily? Do you drink alcohol? Yes No Former Year Quit? Type? How much per week? Amount? Last Drink? Do you have a preferred pharmacy? Yes No Pharmacy: Phone Number: Address: Pharmacy: Phone Number: Address: Immunizations Pediatric Immunizations Please check and indicate the immunization date to all that apply. Series # 1 Series # 2 Series # 3 Series # 4 Series # 5 of last Hepatitis B (HBV) / / / / / / / / / / Diphtheria, Tetanus, Pertussis (DTaP) / / / / / / / / / / Haemophilus influenzae type b (Hib) / / / / / / / / Polio (IPV, OPV) / / / / / / / / Pneumococcal Conjugate (PCV7) / / / / / / / / / / Pneumococcal Polysaccharide (PCV23) / / / / Measles, Mumps, Rubella (MMR) / / / / Varicella (Chicken Pox) (VAR) / / / / Influenza (LAIV) / / / / / / Meningococcal (MCV4/MPSV4) / / / / Tetanus & Diphtheria (Td) / / / / Teenage Tetanus, Diphtheria, Pertussis (Tdap) / / Hepatitis A (HAV) / / / / / / Rotavirus (ROTA) / / / / / / Human Papillomavirus (HPV) / / / / / / Adult Immunizations Please check and indicate the immunization date to all that apply. Series # 1 Series # 2 Series # 3 Series # 4 Series # 5 of last Hepatitis B (HBV) / / / / / / / / / / Pneumococcal (PPV23) / / / / Measles, Mumps, Rubella (MMR) / / / / Varicella (Chicken Pox) (VAR) / / / / Influenza (LAIV) / / / / / / Meningococcal (MCV4/MPSV4) / / / / Tetanus & Diphtheria (Td) / / / / / / / / / / / / Adult Tetanus, Diphtheria, Pertussis (Tdap) / / Hepatitis A (HAV) / / / / / / Varicella Zoster (ZOS) / / Human Papillomavirus (HPV) / / / / / /
6 Health Maintenance of last Disease Management of last Lipid Panel Yes No / / Abdominal Ultrasound Yes No / / Stool cards for hidden blood Yes No / / Cardiac Stress Test Yes No / / History and Physical Yes No / / Chest X-Ray Yes No / / Colonoscopy Yes No / / Echocardiogram Yes No / / Sigmoidoscopy Yes No / / EKG Yes No / / Influenza Vaccine Yes No / / Eye Exam Yes No / / Pneumococcal Vaccine Yes No / / Foot Exam Yes No / / Tetanus Vaccine Yes No / / Pulmonary Function Tests Yes No / / DEXA Scan Yes No / / Gyn Exam Yes No / / PAP Yes No / / Mammogram Yes No / / Breast Exam Yes No / /
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Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider:
New Patient History & Intake Form Patient Information Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider: Preferred
Patient registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
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
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
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:
INFINITY PRIMARY CARE
INFINITY PRIMARY CARE ADULT HISTORY FORM PLEASE PRINT (with Blue or Black Ink) Today s Date: Physician: (last) (first) Date of Birth: Mail Order Pharmacy: Phone: Fax: Local Pharmacy: Phone: Fax: Language
MEDICAL/SURGICAL HISTORY FORM
MEDICAL/SURGICAL HISTORY FORM / / Date: / / Surgical Patients Only: Please check the weight loss procedure that you are interested in: Gastric Bypass Lap Band Undecided Revision of Previous Surgery HT
Preventive health guidelines As of May 2017
Preventive health guidelines As of May 2017 What is your plan for better health? Make this year your best year for wellness. Your health plan may help pay for tests to find disease early and routine wellness
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
PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
Twin Cities Orthopedics Intake Form Do you have a primary care physician?
Twin Cities Orthopedics Intake Form Do you have a primary care physician? Were you referred by a physician? No Yes Please list the MD: Name: Clinic: No Yes Please list the MD: Name: Clinic: Address: Address:
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Primary Care Physician: If Yes, where? Current work status: Full-Time Part-Time Self-Employed Unemployed Disability Retired
Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
Service Bundle 1 Appendectomy - Outpatient 2 Asthma 3 Back Pain - Lumbar Diskectomy 4 Back Pain - Lumbar Fusion 5 Back Pain - Lumbar Laminectomy 6
1 Appendectomy - Outpatient 2 Asthma 3 Back Pain - Lumbar Diskectomy 4 Back Pain - Lumbar Fusion 5 Back Pain - Lumbar Laminectomy 6 Birth Control - Cut and Tie Tubes 7 Bladder Exam - Cystoscopy 8 Bunion