ADULT INFORMATION SHEET
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- Christiana Butler
- 5 years ago
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1 DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: ADDRESS: OCCUPATION: WORK PHONE #: SINGLE MARRIED WIDOWED SEPARATED DIVORCED SPOUSE S FULL NAME: LAST FIRST MI BIRTHDATE: SOCIAL SECURITY #: SPOUSE S PLACE OF EMPLOYMENT OCCUPATION WORK PHONE: HOW WOULD YOU LIKE TO BE NOTIFIED FOR APPOINTMENT CONFIRMATION? PHONE * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** HOW DID YOU HEAR ABOUT OUR CLINIC? ** WHO IS RESPONSIBLE FOR THIS BILL? ** WHICH PHYSICIAN REQUESTED THIS CONSULTATION? CITY/STATE ** FAMILY DOCTOR? CITY/STATE ** WHO CAN WE CONTACT IN CASE OF EMERGENCY? RELATIONSHIP: PHONE #: ** I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATIO NNECESSARY TO PROCESS ANY CLAIM FILED OR RELEASE MEDICAL RECORDS ON MY BEHALF. ** I ALSO ASSIGN ANY BENEFITS FROM MY INSURANCE COMPANY LISTED ABOVE TO THE PHYSICIAN FOR SERVICES DESCRIBED ON THE CLAIM FORM. FINANCIAL AGREEMENT: I fully understand that I am ultimately responsible for any and all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court costs, attorney fees, and any other charges incurred in the collection of any balance due. SIGNED: DATE: SPRINTPRINT
2 PAGE 1 OF 3 PATIENT NAME: DATE OF BIRTH: NEVER SMOKER: X CURRENT SMOKER: complete below FORMER SMOKER: complete below # Packs Per Day: Year You Quit: SMOKELESS TOBACCO? # Cigarettes Per Day: # Packs Per Day Used to Smoke: How Many Years Smoking?: # Years You Smoked: DRINK ALCOHOL : NO: YES: (if yes complete below) 1. SOCIALLY 2. INFREQUENTLY 3. FREQUENTLY 1. BEER 2. LIQUOR 3. WINE # Drinks per Week # Drinks Per Month RECREATIONAL DRUG USE? Yes / No : (LIST TYPE): SURGERIES: LIST ALL SURGERY THAT THE PATIENT HAS HAD: Date of Last Flu Shot, MONTH AND YEAR: Date of Last Pneumonia Shot, MONTH AND YEAR: FAMILY (Mother, Father, Sister, Brother, Daughter, Son) MEDICAL HISTORY : (M) Mother ; (F) Father ; (S) Sister ; (B) Brother; (D) Daughter ; (SON) Son ADOPTED HISTORY UNKNOWN FOOD ALLERGY-(LIST) ALZHEIMER S ASTHMA CORONARY ARTERY DISEASE CANCER (LIST TYPE): GERD (ACID REFLUX) HEADACHES/MIGRAINES HEART DISEASE KIDNEY DISORDER SLEEP APNEA SEIZURES CHRONIC SINUS PROBLEM THYROID DISORDER ALLERGIC RHINITIS PET ALLERGY ARTHRITIS AUTISM COPD DIABETES FIBROMYALGIA HEARING LOSS HIGH BLOOD PRESSURE MENIERE S DISEASE PARKINSON S SKIN DISORDER STROKE VERTIGO (dizziness) COMPLETE NEXT 2 PAGES
3 PATIENT S MEDICAL CONDITIONS (NONE): PAGE 2 OF 3 ADHD ALCOHOLISM ALLERGY TESTS MILK ALLERGY PET ALLERGY ALZHEIMER S ANXIETY ASTHMA AUTISM CHEST PAIN COPD DENTAL CAVITIES DIABETES FIBROMYALGIA GERD (ACID REFLUX) HEARING LOSS HEART DISEASE HEPATITIS (Type): HIGH CHOLESTEROL IMPACTED EAR WAX IRRITABLE BOWEL SYNDROME LARYNGEAL CANCER LUPUS MIGRAINES OSTEOARTHRITIS EAR INFECTIONS, CHRONIC PARKINSON S SEIZURE DISORDER SINUS INFECTION PARAthyroid DISORDER VERTIGO (DIZZINESS) CURRENT SMOKER OTHER CONDITION- PLEASE LIST: (X ) CURRENT (X )PAST (X) CURRENT (X) PAST CANCER (LIST Type): ALLERGIC RHINITIS EGG ALLERGY PEANUT ALLERGY SEAFOOD ALLERGY ANEMIA ARTHRITIS / RHEUMATOID ARTHRITIS ATRIAL FIBRILLATION NECK PAIN CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE DEPRESSION EMPHYSEMA TOBACCO SMOKE EXPOSURE AT HOME GRAVE S DISEASE HEART ATTACK HIGH BLOOD PRESSURE HUMAN IMMUNODEFICIENCY VIRUS / HIV HIGH LIPIDS INSOMNIA KIDNEY DISORDER HOARSENESS MENIERE S DISEASE MITRAL VALVE DISORDER OSTEOPOROSIS SLEEP APNEA: CPAP or BIPAP CHRONIC SORE THROAT / TONSILLITIS SKIN DISORDER STROKE THYROID DISORDER: Nodule, HYPOthyroid, HYPERthyroid; Goiter VISUAL IMPAIRMENT: Glasses, Contacts SEXUALLY TRANSMITTED DISEASE OTHER CONDITION: COMPLETE NEXT PAGE
4 PAGE 3 OF 3 NAME & LOCATION OF YOUR LOCAL PHARMACY: Name of Pharmacy: Location of Pharmacy: ALLERGIC TO: LIST BELOW ALL MEDICINE THE PATIENT IS ALLERGIC TO: MEDICATION: LIST BELOW ALL MEDICINE THE PATIENT IS PRESENTLY TAKING: 1. NAME OF MEDICATION 2.DOSAGE/Milligrams 3.HOW MANY TIMES PER DAY FINAL PAGE
5 Ear, Nose and Throat Physicians, P.A. Consent for Treatment Patient Name: Date of Birth: Relationship to Patient: CHILDREN (FAMILY MEMBERS ONLY) PLEASE LIST ALL PERSONS THAT MAY BRING YOUR CHILD TO OUR CLINIC AND THAT WE MAY TALK TO REGARDING YOUR CHILD S CARE AND TREATMENT: (EXAMPLE: GRANDPARENTS, AUNTS/UNCLES, ETC.) ONLY PARENTS OR LEGAL GUARDIANS MAY SIGN CONSENTS FOR SURGERY OR GET COPIES OF MEDICAL RECORDS. ADULTS (FAMILY MEMBERS ONLY) PLEASE LIST ALL PERSONS WHO MAY HAVE ACCESS TO YOUR MEDICAL RECORD: SIGNATURE OF PATIENT, PARENT, OR GUARDIAN DATE
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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
PATIENT DEMOGRAPHIC INFORMATION
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New Patient Paperwork
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Patient Information. Insurance Information
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Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
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PATIENT INFORMATION FORM (PLEASE PRINT)
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Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
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GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
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FROST FAMILY MEDICINE
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
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Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
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Please complete and return to the office prior to your appointment.
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
NEW PATIENT INFORMATION RECORD PATIENT INFORMATION
Zumbro Vein Institute NEW PATIENT INFORMATION RECORD PATIENT INFORMATION 501 Blackburn Drive Martinez, GA 30907 706-854-8340 Fax: 706-854-8341 www.veinsaugusta.com First Name: Last Name: MI: Social Security
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
PLEASE NOTE: This file must be saved to your desktop before and after completing!
PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select