WALLACE FAMILY PRACTICE, P.A. PATIENT REGISTRATION

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1 WALLACE FAMILY PRACTICE, P.A. PATIENT REGISTRATION DATE: PATIENT INFORMATION: DR. LIC#: SOC. SEC. #: REFERRED BY: PATIENT NAME: M F DATE OF BIRTH (LAST) (FIRST) (MIDDLE) (CIRCLE ONE) ADDRESS: APT. #: CITY: STATE: ZIP: HOME PHONE: ( ) CELL PHONE: ( ) ADDRESS: EMPLOYER: OCCUPATION: ADDRESS: BUS. PHONE: ( ) CITY: STATE: ZIP: PARENT/GUARDIAN INFORMATION: PARENT/GUARDIAN NAME: RELATIONSHIP TO PATIENT: ADDRESS: APT. #: CITY: STATE: ZIP: HOME PHONE: ( ) WORK PHONE: ( ) EMERGENCY CONTACT: RELATIONSHIP TO PATIENT: ADDRESS: APT.#: CITY: STATE: ZIP: HOME PHONE: ( ) WORK PHONE: ( ) INSURANCE INFORMATION: INSURANCE NAME: POLICY ID#: POLICY HOLDER S NAME: POLICY HOLDER S SOCIAL SECURITY NUMBER: POLICY HOLDER S DATE OF BIRTH:

2 WALLACE FAMILY PRACTICE, P.A. PATIENT REGISTRATION HEALTH HISTORY QUESTIONNAIRE TODAY S DATE: LAST NAME: FIRST NAME: MI BIRTHPLACE EDUCATION LEVEL SINGLE MARRIED SEPERATED DIVORCED WIDOWED WHO LIVES AT HOME WITH YOU? MEDICAL HISTORY PLEASE CHECK ANY CONDITIONS YOU HAVE NOW OR HAVE HAD IN THE PAST HEART DISEASE CANCER RHEUMATIC FEVER ANEMIA STROKE BREAST LUMP TUBERCULOSIS BLEEDING DISORDER DIABETES PROSTATE PROBLEM HEPATITIS THYROID PROBLEM HIGH BLOOD PRESSURE CATARACTS HERPES KIDNEY DISEASE HIGH CHOLESTEROL GLAUCOMA VENEREAL DISEASE LIVER DISEASE ASTHMA MIGRAINE HEADACHES HIV/AIDS ANXIETY/DEPRESSION EMPHYSEMA EPILEPSY ARTHRITIS ALCOHOL/DRUG ABUSE OTHER (LIST BELOW): HOSPITALIZATIONS LIST ALL HOSPITALIZATIONS FOR ILLNESS OR SURGERY BEGINNING WITH THE MOST RECENT. DATE REASON HOSPITAL PHYSICIAN MEDICATIONS, VITAMINS, SUPPLEMENTS OUR STAFF WILL ENTER YOUR PRESCRIPTION MEDICATIONS INTO OUR ELECTRONIC MEDICAL RECORD SYSTEM. PLEASE HAVE THAT INFORMATION READY. CIRCLE THE FOLLOWING NON-PRESCRIPTION MEDICATIONS THAT YOU USE. LAXATIVES ANTACIDS ASPIRIN IBUPROFEN OR NAPROXEN DECONGESTANTS ALLERGY PILLS NASAL SPRAYS NATURAL HORMONES VITAMINS HERBS (PLEASE LIST) SUPPLEMENTS OTHER (LIST BELOW): ALLERGIES IF YOU ARE ALLERGIC TO ANY OF THE FOLLOWING PLEASE DESCRIBE THE REACTION YOU HAD. PENICILLIN SULFA OTHER LIFESTYLES AFFECTING HEALTH PLEASE ANSWER THESE QUESTIONS. WEIGHT: NOW 1YEAR AGO DESIRED HABITS: USE SEAT BELTS % 50-80% LESS THAN 50% TOBACCO: NEVER AGE STARTED AGE STOPPED CIGARETTES: #PACKS A DAY CIGARS PIPE SNUFF CHEWING TOBACCO ALCOHOL: NEVER #0-6 DRINKS/WEEK 7-14 DRINKS/WEEK OVER 14/WEEK CAFFEINE: DRINKS PER DAY SPECIAL DIET? TYPE EXERCISE: TYPE: FREQUENCY, DISTANCE, OR AMOUNT: WOMEN: DO YOU DO REGULAR BREAST SELF-EXAMS? YES NO MEN: DO YOU DO REGULAR TESTICULAR SELF-EXAMS? YES NO

3 Patient Name: FAMILY HISTORY FAMILY HISTORY Father Mther 1. Brther/Sister 2. Brther/Sister 3. Brther/Sister 4. Brther/Sister Spuse 1. Sn/Daughter 2. Sn/Daughter 3. Sn/Daughter 4. Sn/Daughter If living If Deceased Family Disease Relatinship t patient Age Health Age Cause Allergies Asthma Arthritis Glaucma Cancer what kind? Tuberculsis Diabetes Heart truble High Bld Pressure Strke High Chlesterl Stmach ulcers Epilepsy/Seizure Substance abuse Anxiety Depressin Suicide Kidney truble Birth defects Sickle cell anemia Mental retardatin PREVENTIVE SERVICES List the date yu last had these preventive medical services r tests. Physical examinatin: Physician: Heart Disease Preventin: High chlesterl: Lipid prfile Cancer Screening: Breast cancer: Mammgram Cervical cancer: PAP smear Cln cancer: Clnscpy OR stl test plus flexible sigmidscpy Infectius Disease Preventin: (List year f mst recent immunizatin) MMR Tetanus Hepatitis B Flu Pneumnia Hepatitis A Osteprsis Screening: DEXA Scan (bne density test) MENSTRUAL HISTORY Age at nset Date f last perid Usual duratin f flw days Pain r cramp? Taking birth cntrl pills? Have an IUD? Ttal Pregnancies Cycle (frm start t start) days (ie: 28 days) If pst-menpausal, age at last perid Flw is: Heavy Medium Light Perids irregular? Have had vaginal infectins r frequent discharge? Have had abnrmal PAP? Number f children brn alive?

4 PATIENT NAME: REVIEW OF SYSTEMS: Please circle any symptms yu have had in the past 6 mnths. Nt circling a symptm means yu have nt experienced it. General Eyes Ear/Nse/Thrat Cardivascular Fevers Blurring Earache Chest Pain Chills Duble visin Ear discharge Fainting Sweats Irritatin Decreased hearing Shrtness f breath Lss f appetite Discharge Nasal cngestin walking Fatigue Visin lss Nse bleeds Shrtness f breath Weakness Eye pain Sre thrat laying flat Malaise Eye pain in light Harseness Shrtness f breath Weight lss Difficulty swallwing at night Leg swelling Respiratry Gastrintestinal Female Geniturinary Male Geniturinary Cugh Nausea Vaginal discharge Pain with urinatin Shrtness f breath Vmiting Incntinence Bld in urine Excessive sputum Diarrhea Pain with urinatin Discharge Cughing up bld Cnstipatin Bld in urine Urinary frequency Wheezing Change in bwel habits Get up at night t urinate Urinary hesitancy Pleurisy Abdminal pain Urinary frequency Incntinence Black stl Missed perid Get up at night t Bldy stl Heavy perid urinate Jaundice Abnrmal vaginal bleeding Decreased libid Gas/Blating Pelvic pain Erectile dysfunctin Indigestin/heartburn Genital sres Genital sres Pain with swallwing Painful intercurse Decreased sexual drive Musculskeletal Skin Neurlgical Mental Back pain Rash Paralysis Depressin Jint pain Itching Numbness Anxiety Jint swelling Dryness Seizures Memry lss Muscle cramps Suspicius lesins Tremrs Suicidal thughts Muscle weakness Vertig Hallucinatins Stiffness Lss f visin Parania Arthritis Frequent falls Phbia Sciatica Frequent headaches Cnfusin Restless legs Difficulty walking Leg pain at night Leg pain with exercise Weakness Fainting Headache Endcrine Heme/Lymphatic Allergic/Immunlgic Cld intlerance Abnrmal bruising Hives Heat intlerance Abnrmal bleeding Allergic rash Increased thirst Enlarged lymph ndes Sneezing Eating mre Hay Fever Urinating mre Recurrent infectins Weight change HIV expsure

5 MEDICATION HISTORY AUTHORITY Patient name: Date: DOB: I,, give Wallace Family Practice, P.A. the authrity t dwnlad my medicatin histry frm all and any pharmacies. Patient Signature (Parent/Guardian t sign if patient is a minr r unable t sign) Date

6 WALLACE FAMILY PRACTICE, P.A. PATIENT REGISTRATION OFFICE POLICIES The fllwing sets frth the general billing plicy, missed appintment plicy, and prescriptin refill plicy f Wallace Family Practice, P.A. Please review this infrmatin and sign where indicated. I understand that it is my respnsibility t prvide the ffice f Wallace Family Practice, P.A., with current and accurate insurance/billing infrmatin at the time f check in and t ntify the ffice f any changes in this infrmatin. I understand that it is my respnsibility t knw my c-pay/c-insurance/deductible. I will pay at the time that services are rendered. I understand that this is a cntractual agreement that I have with my health plan and that the ffice als has a cntractual agreement with my health plan. I understand that if I present an insufficient funds check (NSF CHECK) fr payment n my accunt that I will be charged $35 NSF fee. I understand that in rder t rectify my accunt, I will be required t pay cash r credit. I understand that I will be billed fr any amunts due by me and I have a financial respnsibility t pay these amunts in a timely manner. I understand that I will be prvided with fur (4) mnthly statements fr any balance due after insurance payment. Any utstanding balance f mre than ninety (90) days may affect my ability t make future appintments and /r receive medicatin refills. Any utstanding balance f mre than ninety (90) days withut effrt t make payment may result in terminatin frm the practice fr nn-payment. I understand that there is a $20 fee (payable prir t cmpletin) t cmplete any disability paperwrk assciated with my care. I understand that I will keep any and all appintments fr ffice visits and/r diagnstic prcedures. If I am unable t keep my appintment, I will kindly give 24 hurs ntice. I understand that if I miss tw (2) cnsecutive appintments withut ntice f cancellatin, I may be dismissed frm the practice. I understand that my accunt must be current prir t scheduling anther appintment. I will bring all my prescriptin medicatins t every appintment. Medicatins will be reviewed fr accuracy, apprpriate dsing, and number f refills remaining. Refills will be given at the time f the appintment. I understand that Dr. Wallace reserves the right t deny refills if it has been mre than six (6) mnths since my last appintment. Signature Print Name Date

7 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknwledge that I have received a cpy f Wallace Family Practice s Ntice f Privacy Practices. Patient Name: If yu re nt the patient, please state relatinship: Parent(s) Legal Guardian Sn r Daughter Facility Caretaker Other T respect yur privacy please tell us hw we may cntact yu: Hme/Cell Phne Yu may leave a message with the fllwing persn(s) if I am nt available: Yu may leave DETAILED INFORMATION n my answering machine/vic . Yu may leave NAME AND PHONE NUMBER ONLY n my answering machine/vic and I will return yur call. Wrk Phne Yu may call my wrkplace. Yu may leave DETAILED INFORMATION n my answering machine. Yu may leave NAME AND PHONE NUMBER ONLY n my answering machine and I will return yur call. Yu may NOT call my wrk place. Please list family, friends, et cetera that we may cmmunicate with in regards t yur persnal infrmatin, which includes yur health and billing recrds. Patient s Signature: Date: If nt patient, state relatinship t patient

8 WALLACE FAMILY PRACTICE, P.A. PATIENT REGISTRATION SUMMARY OF PRIVACY PRACTICES This summary f ur privacy practices cntains a cndensed versin f ur Ntice f Privacy Practices. Our full-length Ntice fllws this summary. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY. We understand that yur medical infrmatin is persnal t yu, and we are cmmitted t prtecting the infrmatin abut yu. As ur patient, we create medical recrds abut yur health, ur care fr yu, and the services and/r items we prvide t yu as ur patient. By law we are required t make sure that yu are prtected health infrmatin is kept private. Hw will we use r disclse yur infrmatin? Here are a few examples (fr mre detail please refer t the Ntice Privacy Practices that fllws this summary): Fr medical treatment T btain payment fr ur services In emergency situatins Fr appintment and patient recall reminders In respnse t certain request arising ut f lawsuits r ther disputes T run ur practice mre efficiently and ensure all ur patients receive quality care If yu believe yur privacy rights have been vilated, yu may file a cmplaint with the practice r with Secretary f the Department f Health and Human Services. T file a cmplaint with the practice, cntact ur ffice manager. All cmplaints must be submitted in writing. Yu will nt be penalized fr filing a cmplaint. Yu have certain rights regarding the infrmatin we maintain abut yu. These rights include: The right t inspect and cpy The right t amend The right t an accunting f disclsures The right t request restrictins The right t a paper cpy f this ntice The right t request cnfidential cmmunicatins Fr mre infrmatin abut these rights, please see the detail Ntice f Privacy Practices.

Patient Information Packet Date:

Patient Information Packet Date: Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email: