Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:

Transcription

1 36320 Inland Valley Drive Suite 201 Wildomar, CA Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: address: Date of birth: SSN: Would you like to receive information from our office through our patient portal? Marital Status: Gender: Home Address: City, State: Zip Code: Occupation: Employer Name: Employer Phone: Employer Address: Referring Physician: Primary Physician: Pharmacy: Primary Insurance Information: Insurance Name: Policy Number: Subscribers Name: Subscribers DOB: Subscribers SSN: Relation to Patient: Subscribers Gender: Subscribers Phone #: Secondary Insurance Information: Insurance Name: Policy Number: Subscriber Name: Subscriber DOB: Subscriber SSN: Relation to Patient: Subscribers Gender: Subscribers Phone #: I authorize payment of medical benefits be made directly to the physicians provider for services rendered. I authorize my insurance company, employer, hospital, physician to release any information to this claim and expenses reported. Patient/ Guardian Signature Date

2 General History Form Name: Age: Height: Weight : Reason for Visit: Any Allergies to Medications- NO/ YES (list): Allergy to (circle all that apply): LATEX TAPE IV DYE SOY Current Prescriptions and Dosage: Do you currently take Aspirin or Blood Thinners- NO/ YES (type/dosage/frequency): Non- Prescription/ Herbal remedies: Patient Medical History (mark all that apply): High Blood Pressure Prostate Problems Asthma Jaundice Tuberculosis Thyroid Problems Stroke Colitis/ Polyps Kidney Disease Blood Clots Pacemaker Defibrillator Heart Murmur Heart Attack/ Failure, Date: Diabetes, Insulin or Pills: Hepatitis, Type: Cancer, Type: Any other serious illnesses you have had that DID NOT require surgery: Previous Surgeries and Dates: Do you currently have: (mark all that apply): Congestion Sinus Pain Sore Throat Chest pain Palpitations Shortness of Breath Productive Cough Wheezing Blood in Stool Loss of Appetite Nausea Vomiting Abdominal Pain Heartburn Constipation Diarrhea Fever Fatigue Changes in Weight Night Sweats Rash Itching Nipple Discharge Breast Tenderness Breast Masses Headache Dizziness Loss of Consciousness Numbness Joint Pain Swelling Change in Bowel Movements Family History (mark all that apply): High Blood Pressure Diabetes Heart Disease Bleeding Tendencies Tuberculosis Stroke Kidney Disease Problems with Anesthesia Cancer, Type: Relation: Do you use: Tobacco? NO YES If yes or if you ve quit, how many packs per day? Packs/ day # of years Alcohol? NO YES If yes, how many drinks per week? None 1-2 More than 2 Illicit Drugs? NO YES If yes, please explain: type, duration, and frequency:

3 Bariatric Evaluation Age when you first became overweight: Age when you first began dieting: What is your ideal weight, and when do you hope to achieve it by? : Past Weight loss attempts: Diet Program Pounds lost Year Duration Supervising MD Jenny Craig Nutri-System Opti-Med Fast Over-Eaters Anonymous Fen-Phen Weight Watchers Redux Medi-Fast Behavior Modification Weight No More Others: Medical History: High Blood Pressure Diabetes Sleep Apnea CPAP Y N Heartburn Acid Reflux Hiatal Hernia High Cholesterol or Triglycerides Coughing or Choking at Night Leaking of urine Joint Pain Back Pain Arthritis Thyroid Disease Heart Disease Heart Disease Blood Clots Depression Eating Disorder Psychiatric Disorder Gallbladder Disease Others: Please list all previous Doctors you have seen for weight management: Name: Name: Phone Year treated: Phone: Year treated: Past weight loss surgeries Surgery type Date of surgery (month and year) Name of Surgeon Gastric Bypass Gastric Sleeve Lap Band Referral Source How did you hear about us? If by friend, Doctor, or website, please specify: Attestation I attest that the above information I have provided is true and correct to the best of my knowledge Patient signature: Date:

4 Assignment of Benefits Inland Valley Drive Suite 201 Wildomar, CA I, the undersigned, have insurance coverage and directly assign all medical benefits to Murrieta Valley Surgery Associates for services rendered. I hereby authorize Murrieta Valley Surgery Associates and/or their representatives to release all information necessary to obtain payment of insurance benefits. I authorize the use of this signature on all insurance claims submitted on my behalf. I consent for care and treatment as required by the physician. Once my signature is obtained, Murrieta Valley Surgery Associates may submit any later medical claims without obtaining additional signatures. All claims submitted on my behalf from this date forward will indicate Signature on File in the space provided on the claim form. Patient Name (print): Date: Patient or Parent/Guardian Signature: I wish for the following people to have access to all of my medical records (Family, friends, caretakers, other physicians, etc.): I,, have had an opportunity to review the Notice of Privacy Practices which is attached to this registration packet. I understand that I may request a copy of this form for my personal use at any time. I have also reviewed the attached Office Policies for Murrieta Valley Surgery Associates. Signed: Date:

5 Race/ Ethnicity Form Inland Valley Drive Suite 201 Wildomar, CA Please select one from each of the following THREE (3) categories: Race: (select one) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race White Preferred Language: (select one) Arabic Hebrew Somali Bulgarian Hindi Spanish Central Khmer Italian Swahili Chinese Japanese Thai English Korean Urdu French Polish Vietnamese German Portuguese Russian Haitian Ethnicity: (select one) Hispanic or Latino Not Hispanic or Latino Not Reported/ Unknown