Providence Medical Group

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Transcription:

Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance card/co-pays: Please bring your insurance card with you to your appointments. If you have a prescription card, bring this as well. Please plan to pay your co-pay or your portion of the cost of the visit when you arrive. Prescription Refills: At your first visit, your provider will review the medications you are taking. It is Providence s policy to not prescribe or renew current prescriptions for narcotics, tranquilizers or other controlled medications during your first visit. Your provider will decide whether these medications are appropriate for your condition. You can discuss this with your provider at your first visit. For all prescription refills, please plan ahead and call your pharmacy at least 3 business days prior to you needing the prescription refilled. The pharmacy will contact us directly if they need to get approval for the refill. For mail order prescriptions that you need to send in, please give us 3 business days to complete the paperwork and have it ready for you to pick-up. For most mail order refills, you will need to send your request to the mail order pharmacy two weeks before you need the refill. Test Results: We will notify you regarding lab reports by phone or mail. As an added convenience, you can sign up for MyChart during your first visit which gives you online access to your health record, schedule appointments and receive test results. If you have not been contacted with your results two weeks after your appointment, please call our clinic office to follow up. Same day Appointments: We do have same day appointments built into our provider schedules so please contact your home clinic. They will make every effort to have you see your Primary Care Provider (PCP) or another provider in the clinic. We also provide an Urgent Care clinic at PMG Medford Medical Clinic located at 965 Ellendale Drive, Medford. Our Urgent Care is open Monday-Friday 8 am 7 pm and Saturday-Sunday 9 am 3 pm, including most holidays. No appointments are taken and patients are seen on a first-come, first served basis. If your PCP or another provider in your home clinic is not available, we do provide a Walk-in Clinic at Providence Medical Group Central Point. This clinic is open Monday-Friday from 8 am 8 pm and on Saturday from 9 am 5 pm. No appointments are taken and patients are seen on a first-come, first served basis. Please note that this clinic treats short-term, acute issues. Prescription refills for controlled substances are not provided. We appreciate you choosing Providence Medical Group for your health care needs and appreciate your cooperation with our clinic guidelines. We look forward to partnering with you for good health! 1 OF 5

HEALTH HISTORY Name: Date of birth: Prior provider: How did you hear about us? Reason for today s visit: Medical Problems heart disease congestive heart failure atrial fibrillation diabetes neuropathy hypertension high cholesterol asthma, COPD Surgeries (please write date) Tonsils Appendix Gallbladder Hysterectomy reason: seasonal allergies stroke, TIA migraines / tension headaches seizures hepatitis A, B, C heartburn, GERD thyroid: low, high cancer: Ovaries removed Hernia Joint replacement of: Biopsy of: No medical problems kidney stones arthritis gout osteoporosis depression anxiety No surgeries Medications, vitamins, supplements Pharmacy: Name Strength When taken Allergies No known drug allergies Name Reaction Occupation student working retired disabled Job title: Emergency Contact Name: Phone: Are you satisfied with your health? If not, what would you like to do about it? 2 OF 5

REVIEW OF SYSTEMS Name: Date of birth: Constitutional fever chills weight loss / gain fatigue sweats weakness Skin rash itching change in mole Ear, Nose, Throat headaches hearing loss ear ringing ear pain ear discharge nosebleeds congestion sore throat Home not enough food Eyes blurred vision double vision light sensitivity eye pain eye discharge eye redness Cardiac chest pain palpitations short of breath when lying down leg pain when walking leg / ankle swelling waking up short of breath Respiratory cough bloody sputum sputum production short of breath wheezing No symptoms below Gastrointestinal heartburn nausea vomiting abdominal pain diarrhea constipation blood in stool black stool Genitourinary painful urination urgent urination frequent urination blood in urine flank pain leaking urine nighttime urination Musculoskeletal muscle aches neck pain back pain joint pain falls Hematology easy bruising or bleeding allergies unusual thirst Neurological dizziness tingling tremor numbness speech change weakness seizures loss of consciousness Psychiatric suicidal ideas hallucinations anxiety trouble sleeping daytime sleepiness memory loss don t feel saf Tobacco Smoke: cigarettes per day Chew: 1 can per days I would like to quit How have you quit before? Alcohol One drink = 12 oz beer = 5 oz wine = 1 shot = 1.5 oz liquor Men: How many times in the past year have you had 5 or more drinks in a day? None 1 or more Women: How many times in the past year have you had 4 or more drinks in a day? None 1 or more Caffeine Coffee: cups per day Soda: cans per day Energy drinks: per day A U D I T Drugs How many times in the past year have you used a recreational drug or used a None 1 or more prescription medication for nonmedical reasons? Exercise What is your goal for exercise? activity, duration, frequency, intensity Mood During the past 2 weeks, have you been bothered by little interest or pleasure in doing things? No Yes During the past 2 weeks, have you been bothered by feeling down, depressed or hopeless? No Yes 3 OF 5 D A S T P H Q 9

FAMILY HISTORY Name: Date of birth: Children Age Problems Sisters / Brothers Age Problems Father s side Age Problems Grandfather Grandmother Father Aunts Uncles Mother s side Age Problems Grandfather Grandmother Mother Aunts Uncles Cancer Who in your family had this? Age of diagnosis Colon / Rectal Breast Ovarian Uterine / Endometrial Cervical Prostate Melanoma Other (brain, thyroid, lung, pancreatic, stomach, small bowel, kidney, bladder, etc) Are you of Ashkenazi Jewish descent? Yes No Has anyone in your family had genetic testing? Yes No 4 OF 5

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