Union Internal Medicine Specialties, Ltd. 515 Union Ave, Suite 187 Dover, Ohio New Patient Registration Form

Transcription

1 Union Internal Medicine Specialties, Ltd. 515 Union Ave, Suite 187 Dover, Ohio New Patient Registration Form Appointment With: IT IS IMPORTANT TO ARRIVE 20 MINUTES BEFORE YOUR APPOINTMENT YOU WILL NEED TO BRING YOUR INSURANCE CARD AND PHOTO ID. YOU WILL REGISTER WITH THE FRONT DESK AND A NURSE/MEDICAL ASSISTANT WILL TALK TO YOU PRIOR TO SEEING YOUR PROVIDER. First Name: M.I.: Last Name: Birth date: Social Security Number: Gender: M / F Race/Ethnicity: Marital Status: Married / Single / Separated / Divorced/ Partner / Married same sex/ Partner same sex / Other Patient Address: Street City State zip Home # Cell # Alternative # Employment Status: Full time / Part time / Unemployed / Retired / Other Occupation Employer Work Telephone: Emergency Contact: Name Relationship Telephone Number needs to be different from yours Insurance Information Primary Insurance: Policy Number Group Number Primary Card Holder (Husband, Wife, Parent, Self) First name last name Middle Initial Primary Card Holder s DOB: Relationship to patient: Primary Card Holder s Employer: Secondary Insurance: Policy Number Group Number Primary Card Holder (Husband, Wife, Parent, Self) First name last name Middle Initial Primary Card Holder s DOB: Relationship to patient: Primary Card Holder s Employer: Patient/Responsible Party Signature Date:

2 UIMS HEALTH HISTORY Name: Birthdate: Check if you are CURRENTLY experiencing any of the following symptoms: General Cardiovascular Rectal bleeding Men Only Fever Chest pain Hemorrhoids Erectile dysfunction Chills High blood pressure Difficulty swallowing Lump in testicle Sweats Irregular/rapid heartbeat Urinary Penis discharge Headaches Swelling in ankles Recurrent infections Sore on penis Forgetfulness Dizziness Frequency Reduced urinary stream Weight Loss Varicose veins Burning Enlarged prostate Weight Gain Lungs Incontinence Women Only Insomnia Cough Retention Abnormal pap smear Fatigue Coughing blood Musculoskeletal Irregular periods Depression Shortness of breath Joint pain Breast lump Anxiety Wheezing Muscle pain Extreme menstrual pain Excessive thirst Chest congestion Leg cramps Hot flashes Eye, Ear, Nose, Throat Gastrointestinal Swelling Nipple discharge Vision changes Poor appetite Numbness Painful intercourse Hearing loss Bloating/gas Tingling Vaginal discharge Earache Bowel changes Tremors Other Ringing in the ears Constipation Back pain Hay fever Diarrhea Skin Nosebleeds Indigestion Bruising Sinus problems Reflux/heartburn Hives Hoarseness Nausea Rash Bleeding gums Abdominal pain Change in moles Snoring Vomiting Nonhealing ulcers Check if you have a history of any of the following conditions: Alcoholism Anemia Arthritis Asthma Anxiety Atrial fibrillation Bleeding disorder Blood clots Breast lump Cancer Cataracts Chicken pox Circulation problems COPD/emphysema Colon polyps Depression Diabetes Diverticulitis Fibromyalgia Glaucoma Gout Heart disease Hepatitis Herpes High blood pressure High cholesterol HIV Kidney disease Kidney stones Liver disease/cirrhosis Mental illness Migraines Multiple sclerosis Osteoporosis Pneumonia Polio Prostate problems Restless leg Rheumatic fever Seizures Shingles Stomach ulcers Stroke Thyroid problems Tuberculosis Venereal disease Check any surgeries you have had and fill in approximate date: Appendix Back Breast Carpal tunnel Carotid C-section Cataract D&C Gallbladder Hernia Hemorrhoids Heart bypass Heart Stent Tonsils Hip replacement Tubal Hysterectomy Thyroid Knee replacement Mastectomy Pacemaker Check if you have had any of the following and fill in approximate date: Health Maintenance Bone density Colonoscopy Stress Test Immunizations Pneumovax Prevnar13 Zostavax Shingrix Flu Women Only Mammogram Pap Smear Men Only PSA

3 Health History Continued... Family History: Relation Age Living/Deceased Major Medical Conditions Name: D.O.B: Check if any other blood relatives have any of the following conditions: Condition Relationship to you Father Asthma Mother Arthritis, gout Brothers Cancer Diabetes Heart disease High Blood Pressure Sisters Stroke Kidney disease TB Other Social History: Relationship Status (circle): Single Married Divorced Separated Widowed Partner Sexual Orientation (Circle): Straight Gay Lesbian Bisexual Transgender Number of children: Boys Girls Highest level of education (circle): Occupation: Do you have a living will: Yes No Medical Power of Attorney: Smoking Status: Alcohol Use: Grade school High School Trade School College Graduate School Never a Smoker Former Smoker Current Smoker If Former Smoker: If Current Smoker: Age Started Smoking Age Quit Smoking Average amount smoked per day Age Started Smoking Average amount smoked per day Never Former Rare Social/Weekends Daily If Former Drinker: If Current Drinker: Age started drinking: Age quit drinking: Average consumed per day: How many drinks per day on average: Beer Liquor Wine Drug Use: Never Former Current: type/frequency Caffeine Use: None Coffee cups/day Tea cups/day Pop cups/day

4 Health History Continued... Name: D.O.B: Medication Allergies: MEDICATIONS (Please list all meds including prescriptions, over the counter meds, supplements and vitamins) Medication Dosage Frequency

5 New Patient Registration Continued All Insurance Authorization and Assignment I understand and agree that, (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all of the information on this form and have completed all the answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any change in my health insurance status of the above information. Signature of Patient or Responsible Party (Relationship) Date FOR MEDICARE PATIENTS Statement to Permit Payment of Medicare Benefits to Provider, Physician and Patient. I certify that the information given by me in applying for payment under Title VIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to be released to the Health Care Financing Administration, or its intermediaries or carries, any information needed for this or related Medicare claim. I request that pay of authorized benefits be made on my behalf. I assign the benefits payable to covered Medicare services to physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I request that payment under the medical insurance program be made either to me or to Union Internal Medicine Specialties on any bills for services rendered me by Union Internal Medicine Specialties, Ltd. Signature of Patient Date Signed Health Insurance Claim Number