DATE OF FIRST INJURY OR ILLNESS NAME DATE OF BIRTH ADDRESS M F AGE MARITAL STATUS CITY STATE ZIP CODE HOME PHONE NUMBER ( ) WORK PHONE NUMBER ( )

Transcription

1 Tri-Valley Oncology / Hematology Ashwin Kashyap, M.D. Martin Palmer, M.D. E. Lynn Meyering, M.D. 555 Marin St., Suite 200, Thousand Oaks, CA & 2045 Royal Ave # 208, Simi Valley, CA DATE DATE OF FIRST INJURY OR ILLNESS NAME DATE OF BIRTH ADDRESS M_F_ AGE MARITAL STATUS CITY STATE ZIP CODE HOME PHONE NUMBER ( ) WORK PHONE NUMBER ( ) CELLULAR PHONE NUMBER ( ) PATIENT S SOCIAL SECURITY NUMBER - -_ PATIENT S DRIVER S LICENSE NUMBER OCCUPATION EMPLOYER EMPLOYER S ADDRESS CITY STATE ZIP CODE REFERRING/PRIMARY CARE PHYSICIAN SPOUSES NAME _ SOCIAL SECURITY # - - SPOUSES EMPLOYER WORK PHONE NUMBER ( ) SPOUSES DATE OF BIRTH_ IN CASE OF EMERGENCY, PLEASE NOTIFY: ADDRESS PHONE NUMBER CITY STATE ZIP CODE IF PATIENT IS A MINOR, WHO IS LEGALLY RESPONSIBLE? RELATIONSHIP (i.e. mother, father, legal guardian) INSURANCE INFORMATION!!!!!!! PLEASE PRESENT ALL INSURANCE CARDS TO THE RECEPTIONIST SO COPIES CAN BE MADE. PRIMARY INSURANCE CARRIER GROUP # I.D. OR SUBSCRIBER # INSUREDS NAME CO-PAYMENT $ BILLING ADDRESS DEDUCTIBLE $ SECONDARY INSURANCE CARRIER GROUP # I.D. OR SUBSCRIBER #_ INSUREDS NAME CO-PAYMENT $

2 TRI-VALLEY ONCOLOGY HEMATOLOGY ASHWIN KASHYAP, M.D. MARTIN PALMER, M.D. E. LYNN MEYERING, M.D. 555 MARIN ST., SUITE ROYAL AVE. # 208 THOUSAND OAKS, CA SIMI VALLEY, CA PHONE: (805) PHONE: (805) FAX: (805) FAX: (805) AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN I HEREBY AUTHORIZE PAYMENT DIRECTLY TO ABOVE NAMED PHYSICIAN OF THE MEDICAL BENEFITS IF ANY, OTHERWISE PAYABLE TO ME FOR HIS SERVICES DESCRIBED ON ATTACHED CLAIM. DATE SIGNATURE OF INSURED PAYMENT OF SERVICES IF THE INSURANCE PAYMENT WILL NOT SATISFY MY INDEBTEDNESS TO THE ASSIGNEE, I AGREE TO PAY IN A CURRENT MANNER, ANY BALANCE, OR NON-COVERED CHARGES OF SAID PROFESSIONAL SERVICE CHARGES OVER AND ABOVE THE INSURANCE PAYMENT. DATE SIGNATURE OF PATIENT OR RESPONSIBLE PARTY AUTHORIZATION TO RELEASE INFORMATION I HEREBY AUTHORIZE ABOVE NAMED PHYSICIAN TO RELEASE ANY INFORMATION ACQUIRED IN THE COURSE OF MY EXAMINATION OR TREATMENT TO MY SPOUSE/ SIGNIFICANT OTHER. DATE SIGNATURE OF PATIENT OR PARENT IF MINOR RECORDS RELEASE DATE TO (DR. OR HOSPITAL) ADDRESS PHONE NUMBER _( ) CITY STATE ZIP CODE I HEREBY AUTHORIZE YOU TO RELEASE TO ASHWIN KASHYAP, M.D. MARTIN PALMER, M.D. E. LYNN MEYERING, M.D. 555 MARIN ST. # ROYAL AVE. # 208 THOUSAND OAKS, CA SIMI VALLEY, CA PHONE: (805) FAX: (805) PHONE: (805) FAX: (805) THE COMPLETE MEDICAL RECORDS IN YOUR POSSESSION, (WHICH INCLUDE ALL HISTORY, PHYSICAL, LAB, X-RAY, EKG S SCANS AND DISCHARGE) CONCERNING MY ILLNESS AND/OR TREATMENT DURING THE TIME YOU TREATED ME. _ SIGN PRINT WITNESS RELATIONSHIP

3 Current Attending Physicians Patient Name: 1. Physicians Name Address 2. Physicians Name Address 3. Physicians Name Address 4. Physicians Name Address 5. Physicians Name Address

4 ASHWIN KASHYAP, M.D. MARTIN PALMER, M.D. E. LYNN MEYERING, M.D. PATIENT HISTORY QUESTIONNAIRE DATE NAME AGE MARITAL STATUS MALE FEMALE FAMILY HISTORY FATHER MOTHER SIBLINGS SELF AGE LIVING/DEAD INDICATE ILLNESS FOR YOUR SELF BY YES OR NO TUBERCULOSIS DIABETES CANCER HEART DISEASE HYPERTENSION LUNG DISEASE KIDNEY DISEASE ARTHRITIS OTHER (MAJOR ILLNESS OR SURGERY) OTHER: ADDITIONAL NOTES: SOCIAL HISTORY PLEASE INDICATE BY YES OR NO CIGARETTE SMOKER NON-SMOKER FORMER SMOKER_

5 IF YOU ARE A SMOKER OR FORMER SMOKER: AGE STARTED AGE STOPPED AVERAGE PACKS/DAY PACKS/YEARS (PHYSICIAN ONLY) ALCOHOL (IF PERTINENT, PLEASE INDICATE DEGREE OF ALCOHOL INTAKE) OTHERS COFFEE OR TEA (NUMBER OF CUPS PER DAY) MARIJUANA, HEROIN, LSD OR SIMILAR DRUGS: PAST HISTORY PAST SURGICAL HISTORY (PLEASE INDICATE HOSPITALIZATIONS) HOSPITALIZATION ( REASON) MONTH YEAR HOSPITAL CITY/STATE OTHER PERTINENT INFORMATION

6 PAST MEDICAL HISTORY (NOT REQUIRING HOSPITALIZATION) PROBLEM NATURE OF ILLNESS OTHER PERTINENT INFORMATION MEDICATIONS (LIST EVERYTHING YOU TAKE AND HOW OFTEN, INCLUDING VITAMINS, BIRTH CONTROL PILLS, ect.) ALLERGIES TO ANY MEDICATIONS (LIST ALL DRUGS AND NATURE OF THE ALLERIC REACTION)

7 REVIEW OF SYSTEMS PLEASE INDICATE WITH A CHECK ONLY IF THIS IS A PRESENTLY OR HAS BEEN IN THE PAST A PROBLEM. HEAD, EYES, EARS, NOSE, AND THROAT FREQUENT HEADACHES EXCESSIVE SWEATING, NIGHT NECK PAINS HEART DISEASE NECK LUMPS OR SWELLING HIGH BLOOD PRESSURE BLURRY VISION RHEUMATIC FEVER EYESIGHT WORSENING RACING HEART SEE DOUBLE CHEST PAIN SEE HALOS DIZZY SPELLS EYE PAINS OR ITCHING SHORTNESS OF BREATH WATERING EYES SHORTNESS OF BREATH, NIGHT EYE TROUBLE MORE PILLOWS TO BREATHE HEARING DIFFICULTIES SWOLLEN FEET OR ANKLES EARACHES LEG CRAMPS RUNNING EARS HEART MURMUR RINGING IN EARS GASTROINTESTINAL CONGESTED NOSE OBSTRUCTION HEARTBURN RUNNING NOSE BLOATED STOMACH SNEEZING SPELLS BELCHING HEAD COLDS STOMACH PAINS NOSE BLEEDS HISTORY OF ULCERS SORE THROAT PANCREATITIS ENLARGED TONSILS NAUSEA HOARSE VOICE VOMITED BLOOD JAUNDICE &/OR HEPATITIS DENTAL PROBLEMS DIFFICULTY SWALLOWING SWELLING ON GUMS OR JAWS CONSTIPATION BLEEDING GUMS LOOSE BOWELS DENTURES BLACK STOOLS SORE TONGUE GREY STOOLS TASTE CHANGES PAIN IN RECTUM RECTAL BLEEDING CARDIORESPIRATORY GENITOURINARY WHEEZES OR GASPS COUGHING SPELLS NIGHT FREQUENCY COUGHS UP PHLEGM DAY FEQUENCY COUGHED UP BLOOD BURNING IN URINATION CHEST COLDS PAIN DURING URINATION PNEUMONIA BROWN, BLACK OR BLOODY URINE TUBERCULOSIS DIFFICULTY STARTING URINE ASTHMA URGENCY BLOOD CLOTS IN LUNGS STONES VENEREAL DISEASE WEAK URINE STREAM NEURO-PSYCH PROSTATE TROUBLE BURNING OR DISCHARGE FAINTNESS

8 LUMPS ON TESTICLES NUMBNESS PAINFUL TESTICLES CONVULSIONS PARALYSIS MENSTRUAL TROUBLE CHANGE IN HANDWRITING BREAKTHROUGH BLEEDING TREMBLES HEAVY BLEEDING BLEEDING AFTER INTERCOURSE LACK OF CONSENTRATION PAIN WITH INTERCOURSE LACK OF MEMORY PREMENTRUAL TENSION HOT FLASHES HOPELESS OUTLOOK BIRTH CONTROL PILLS WORK OF FAMILY PROBLEMS LUMPS IN BREASTS SEXUAL DIFFICULTIES PAIN OR TENDERNESS IN BREASTS CONSIDERED SUICIDE NIPPLE DISCHARGE DESIRED PSYCHIATRIC HELP VAGINAL DISCHARGE PAP SMEAR ENDOCRINE LAST MENSTRUAL PERIOD MENOPAUSE WEIGHT CHANGES TENDS TO BE HOT OR COLD No. OF NORMAL PREGNANCIES LOSS OF INTEREST IN EATING No. OF NORMAL DELIVERIES ALWAYS HUNGRY MISCARRIAGES MORE THIRSTY LATELY STILLBIRTHS FATIGUE PREMATURE BIRTHS SLEEPING DIFFICULTIES CESAREANS ABORTIONS PHYSICIAN NOTES RELATING TO ABOVE SYSTEMS CONNECTIVE TISSUE ACHING MUSCLES OR JOINTS SWOLLEN JOINTS _ BACK OR SHOULDER PAINS PAINFUL FEET SKIN PROBLEMS _ ITCHING OR BURNING SKIN BLEEDING EASILY _ BRUISES EASILY