NEW PATIENT INFORMATION

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Lorraine Melton
6 years ago
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1 NEW PATIENT INFORMATION Name Female Male Social Security # Date of Birth Age Address Apt # City State Zip Address Cell Phone # Home Phone # Work Phone # Marital Status Married Divorced Separated Widowed Single Whom may we thank for referring you? Do you have health benefits with your employer? Your Employment Status Full-time Part-time Self-employed Retired t employed Name of Employer Phone Address City State Zip Name of Primary Insurance Company Payor Network Effective Date of Coverage Type of Health Plan HMO PPO POS Self-funded Traditional t Sure Policy # Group # Policy Holder s Name Are you covered by health benefits from your spouse or another party? Subscriber s Name Name of Secondary Insurance Company Payor Network Effective Date of Coverage Type of Health Plan HMO PPO POS Self-funded Traditional t Sure Policy # Group # Information About Your Spouse / Significant Other Relationship to you Spouse Parent Other Name Phone Social Security # Date of Birth Address Apt # City State Zip Continue to other side.

2 Employment Status of Spouse / Significant Other Full-time Part-time Self-employed Retired t employed Name of Employer Phone Address City State Zip Guarantor Information (who is financially responsible for the bill?) Relation of the Person to You Name Phone Social Security # Date of Birth Address Apt # City State Zip Emergency Contact Information Name of Emergency Contact Phone # Relationship to You Your Primary Care Physician Name Phone Address Apt # City State Zip I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I have read all the information and have completed the above answers. I certify that I have disclosed all sources of health benefit coverage and that this information is true and correct to the best of my knowledge. I will notify you of all changes. n-covered Items or Services: I have been informed that the items or services listed above may not be covered by insurance and that non-coverage does not mean that I should not receive the items or services. I have been informed that a good faith estimated cost of such items or services is $, but I understand that the items or services could actually cost more or less than this amount. I elect to receive the non-covered items or services and agree to be personally and fully responsible for payment. I understand that you may be contacting my insurance provider and / or employer or the insurance provider and / or employer of my spouse or significant other for the purpose of insurance and benefit verification, and I authorize these contacts. I understand that my health information will be kept confidential and I have been given and hereby acknowledge receipt of the tice of Privacy Practices of Barix Clinics. Signature Date Parent s signature if the patient is a minor

3 PATIENT MEDICAL HISTORY Date: Name: Age: Date of Birth: Gender: Female / Male ALLERGIES: Are you allergic to any medications? If yes, list the medications and describe the reaction below: Medication Reaction Are you allergic to any foods? If yes, list the foods and describe the reaction below: Food Reaction Do you have any other allergies? (dust, mold, weeds, etc.) If yes, please list the substances and describe the reaction below: Substance Reaction Are you allergic to latex products? (example: foam rubber, tennis shoes, balloons)

4 MEDICATIONS: Have you or are you currently taking any of the following types of medications: Anti-Depressant? Anti-Hypertension? Coumadin / Heparin? Insulin? Oral Hypoglycemic? Steroids within the last 6 months? Over the counter? HERBAL PRODUCTS / SUPPLEMENTS: Do you use any of the following? Product Dose Frequency St. John s Wort Kavakava Garlic Ginger Ginkgo Biloba Vitamin K Vitamin E Other Please list any medications you are currently taking (prescribed or over the counter): Drug Dose Frequency Why

5 SUBSTANCE USE: How Much # of Years Quit Y/N Do or have you smoked? Do you or have you drank alcohol? Do you or have you used marijuana? Do you or have you used other drugs? SURGERY HISTORY: Have you had any stomach and/or abdominal surgeries? If yes, please describe below: Surgery Year Complications or Problems Have you had any other surgeries? If yes, please describe below: Surgery Year Complications or Problems ANESTHESIA HISTORY: Have you or a family member ever had complications with anesthesia? If yes, please describe:

6 BREATHING & LUNG HISTORY: Do you have any of the following breathing and/or lung problems? Asthma? Emphysema? COPD? Pneumonia? Cough? Snoring? Daytime fatigue? Seasonal sinus problems? Year round sinus problems Tracheostomy Do you have any difficulty breathing laying down? Do you need extra pillows to help you breathe during sleep? If yes, how many pillows? Do you ever wake up short of breath? Have you ever been diagnosed with Sleep Apnea? Are you on a C-PAP/BIPAP? If yes, what is the setting? Do you experience shortness of breath: At rest? After any exertion? While climbing stairs? Do you have any breathing problems that interfere with everyday activity? If yes, please describe:

7 HEART & CIRCULATORY SYSTEM: Do you have or have you had any of the following heart and/or circulation problems: Anemia? Bleeding Problems? Blood clot Lungs? Blood clots Legs? Chest pains? Congestive heart disease? Edema Feet? Edema Hands? Heart attack (MI)? Heart Murmur? High blood pressure? Low blood pressure? Irregular heart beat? Palpitations? Sickle Cell? Varicose veins? Dizziness? Do any of these problems affect your everyday activity? If yes, how? Have you ever been under the care of a Cardiologist If yes, physician s name: Telephone #:

8 MUSCULOSKELETAL & NEUROLOGICAL SYSTEMS: Do you have any of the following problems? Back pain? Hip pain? Knee pain? Joint problems? Joint stiffness and pain? Arthritis? / Osteoarthritis Gout? Weakness / fatigue? Seizures? Numbness / tingling? Carpal tunnel? Headaches? / Migraines? Major Motor Vehicle Accident? Any Physical Disability? Stroke? Multiple Sclerosis? Are you able to walk on your own? If not, do you use a: cane walker brace wheelchair motorized scooter Do you exercise? Type of exercise # minutes/time #times/week

9 STOMACH & DIGESTION HISTORY: Do you have any of the following stomach, digestion, intestinal, colon, or related problems: Heartburn? Trouble swallowing? Ulcers? Hiatal Hernia? Gall bladder? High cholesterol? Hemorrhoids? Hepatitis? Liver Disease? Colitis? Diverticulitis? Crohn s Disease? Chronic history of nausea/vomiting? Chronic history of constipation? Chronic history of diarrhea? Bloody/black stool? Are you diabetic? If yes, treated with: Diet Medication (Pills) Insulin injections Do you check your blood sugar at home? If yes, how often? Last reading: Did you have gestational diabetes while pregnant? / NA

10 URINARY TRACT & REPRODUCTIVE SYSTEM Do you have any of the following problems? (Female only) Fertility problems? Irregular periods? periods? Cysts in ovaries? / Polycystic Ovary Syndrome? Post menopausal? Endometriosis? Lose urine when you cough or sneeze? Hysterectomy? (Male or Female) Urinary tract infections? Bloody urine? Frequent urination? Difficulty urinating? Kidney Problems? Kidney Stones? (Male Only) Prostate problems? OTHER MEDICAL HISTORY: Do you have or have you had any of the following general problems Skin rashes/itching? Open or draining sores? Major dental, vision, hearing problems? Recent hair loss? Hyperthyroidism / Hypothyroidism? History of cancer?

11 FAMILY HISTORY Do any immediate (mother, father, grandparents, siblings) family members have any of the following medical problems (cancer, high blood pressure, diabetes)? If yes, who? Cancer? Diabetes? High Blood Pressure? Cardiac Disease? PSYCHOLOGICAL & SOCIAL HISTORY: Do you or have or have you ever had a problem with any of the following: If yes, year(s) Depression? Hospitalized for depression? Nervous breakdown? Hospitalized for breakdown? Suicidal thoughts? Hospitalized for suicide attempt? Anorexia? Bulimia? Bingeing? Are you currently being seen by a psychiatrist/psychologist? How long have you been overweight? How long have you been at least 100 pounds overweight? How long have you been at your current weight? Do you have a supportive person(s) in your life?

12 RECENT MEDICAL STUDIES DONE: Have you had any of the following medical tests done within the past year: rmal Abnormal Upper GI? Lower GI? Gastroscopy (scope)? Colonoscopy? Pulmonary function tests? EKG? Cardiac workup including stress Chest X-ray? PAP Smear? Mammogram? Annual Check up including blood work DIET HISTORY: Which of these SUPERVISED PROGRAMS have you tried? #Months Attempted Amount loss Personal Physician Medifast / Optifast Weight Watchers Jenny Craig LA Weight Loss Phen-fen Redux Nutri System / Formu 3 Weight Loss Clinic Curves Other Amount regained Which of these PERSONAL PROGRAMS have you tried? #Months Attempted Amount loss Fasting Slim Fast Deal-a-Meal Lo-cal/Low fat diets Diet Pills Other Amount regained RN / LPN / MA: Date:

Patient Medical History

Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES: