Patient Information Name: (First) (MI) (Last) Date of Birth Age: Sex: M F Marital Status: M S D W Address: (Street) (City,State,Zip) Home Phone # Work Phone # Cell Phone # Social Security # Email Address: Primary Language: Race: Ethnicity: Primary Care Physician: Referring Physician: Employer: Occupation: Phone # Address: (Street) _(City,State,Zip) If, Student, School Name: Grade: Full/Part time: Guardian (POA) if applicable: Phone # Relationship: Emergency Contact Name: Phone # Relationship: Insurance Information (Please provide copy of cards) Medicare # Medicaid # Primary Holder s Name: Date of Birth SS# Group/Policy # Certificate ID # Insurance Company Secondary Phone # Group/Policy # Phone # Pharmacy Name: Phone # Rx Benefit Plan: ****Request for Prescription Refills Requires 72 Hour Notice **** Patient/Guardian Signature Date: To help improve the way we care for our patients and to help ensure you understand doctor s instructions, we have a brief PATIENT SATISFACTION SURVEY you will fill out in the office. Would you be interested in participating in the survey? Yes No
Medical Information Name: Current and past medical conditions (Please check) o Abnormal Heart Rhythm o Diabetes o Breast Cysts/Benign Lesions o Congestive Heart Failure/CHF o Kidney Failure o Glaucoma o Heart attack/mi o Kidney Stones R or L Bilateral o Arthritis o High Blood Pressure o Bladder/Kidney Infections o Elevated Cholesterol o Coronary Artery Disease/Angina o Asthma o Thyroid Disease Low High o Stroke R or L side o COPD/Emphysema o Epilepsy/Seizures o Mini Stoke/TIA R or L side o Tuberculosis o Psychological Problems o CarotidArtery Disease/Narrowing o Stomach/Duodenal Ulcer Cancer Check Below o Arterial Blockage Legs R or L o Hiatal Hernia/Reflux Disease Breast Ovary o Deep Vein Clots R or L o Diverticulosis/Diverticulitis Skin Leukemia o Phlebitis R or L o Colon Ploys Lung Lymphoma o Leg Swelling/Edema o Hemorrhoids Prostate Liver o Varicose Veins o Hepatitis Colon/Rectum Thyroid o Ulcers/Sores of Legs/Feet o HIV/Aids Uterus/Cervix o Aneurysm o Pneumonia Stomach Other Medical Conditions (list) Past Surgeries (please check) o Gallbladder Scope Open o Tubal Ligation Scope Open o Appendectomy Scope Open o Hysterectomy Vaginal/Scope Open o Right Inguinal (groin) Hernia Scope Open o Right Ovary/Tube Scope Open o Left Ingunial (groin) Hernia Scope Open o Left Ovary/Tube Scope Open o Abdominal (Incisional) Hernia Scope Open o Mastectomy Right Left o Umbilical (Naval) Hernia Scope Open o Breast Lumpectomy & Node Removal Right Left o Colonoscopy, 20, Normal Polyp removal o Breast Biopsy Right Left o Stomach Scope/EGD 20 o Kidney Stone Removal Scope Litho(US) Open o Hiatal Hernia Repair/Nissen Scope Open o Kidney Remobal/Nephrectomy Right Left o Colon Resection Scope Open o Prostate Surgery TURP Open/Radial o Other Bowel Resection o Cataract Removal With Lens Right Left o Stoma, Colostomy/Ileostomy Reversal/Closure o Knee Replacement Right Left o Hemorrhoidectomy o Hip Replacement Right Left o Stomach Surgery Ulcer Cancer Weight Lose o Other Orthopedic Surgery: o Tonsillectomy o Heart Catheterization Normal Balloon Stent o Back Surgery Cervical/Neck Lumbar/Low o Pacemaker with Auto Defibrillater Right Left o Skin Cancer Removal o Coronary Artery Bypass with Leg Vein Right Left o Dialysis/Other IV Catheter Right Left o Aneurysm/AAA Repair EVAR/Stent graft Open o Dialysis Access Fistula Surgery Right Left o Carotid Artery repair Stent Open Right Left o Dialysis Access Graft Surgery Right Left o Leg Artery Repair/Catheter Procedure Right Left o Varicose Vein Procedures (Laser/VNUS) Right Left o Leg Artery Repair/Bypass Procedure Right Left o Varicose Vein Stripping Right Left Other Surgeries (list) Reviewed Physician MA/RN/LPN: Date:
Name Medical Information (Please Print; we will assist you as needed) Primary Care Physician: Referring Physician Medications (Include Over the counter, vitamins, supplements) Use Back if Needed Name Dose (if Known) How often Taken Allergies to Drugs: Other Allergies: Social History (Circle answers) Smoking: Never Quite Years ago Now smoking Pack/Day for Years Quitting Now Alcohol: Never Monthly Weekly Daily Alcoholic Quit years ago Quitting Now Drugs: Never IV Drugs Marijuana Cocaine Quite years ago Quitting Now (In Rehab) Family Medical History Family Member Age(s) Deceased Medical Problems (List) Son(s) Daughter(s) Father Mother Brother(s) Sister(s) Paternal Grandfather Maternal Grandfather Paternal Grandmother Maternal Grandmother Other Family medical History Reviewed: MA/LPN/RN Date
Medication History Notice: Acknowledgement Patient Name: Date of Birth: I,,understand that my physician may need access to my medication history and may work in conjunction with my pharmacy in order to provide accurate medical treatment. Patient Signature Date Personal Representative Signature Relationship to Patient For Office Use Only: o o o o Patient refused to sign Patient unable to sign due to communication/language barrier Patient unable to sign due to emergency situation Other (please explain) Office Representative Signature Date
Identification of Personal Representative Name of Patient Date of Birth Home Phone I hereby grant the individual(s) named below access to my protected health information. This individual may receive and act upon information received from Tennova Medical Group. This information may include clinical information about my care, as well as billing information related to my insurance coverage and payment activity for the services rendered by Tennova Medical Group. Signature Date signed Personal Representative DOB: Daytime Phone# Personal Representative DOB: Daytime Phone# Personal Representative DOB: Daytime Phone# Requests may be mailed to the Privacy Officer: Tennova Medical Group 647 Dunlop Lane # 203 Clarksville, TN 37040 For Official Use Only Received by: Date Reviewed by: Date Date Notation made in electronic chart
Cancellation Policy/No Show Policy Your procedure time has been reserved specifically for you. If you are unable to keep your appointment a 2 business day cancellation notice is required to avoid a $100.00 cancellation fee. Patients who miss an appointment without contacting the office to cancel or reschedule will be charged a $100.00 fee. These fees are NOT billable to your Insurance Carrier and will be your responsibility. Thank you If you have questions or concerns please contact the office at 931-502-3810 Patient Signature Date
Authorization For Release of Medical Information To Tenova Medical Group I,, authorize, Patient name Health Care Provider To release to Tennova Medical Group Clarksville, Tennessee for the purpose of patient treatment, medical and/or psychiatric information covering the following dates: Including specifically the following portions of the records: This authorization expires 90 days from the date below and it covers only treatment prior to that date. ****ALL BLANKS MUST BE COMPLETED **** Print Patient s Full Name Patient s Signature Date of Birth Date Social Security Number Witness