PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET CITY STATE ZIP CODE PHONE: Home ( ) Work ( ) Cell ( ) PREFERRED WAY OF CONTACT: Home Work Cell DATE OF BIRTH: AGE: SEX: MALE FEMALE SOCIAL SECURITY # - - RACE/ETHNICITY: LANGUAGE: HEIGHT WEIGHT SHOE SIZE MARITAL STATUS: MARRIED SINGLE SEPARATED DIVORCED OTHER DO YOU USE TOBACCO? YES NO EXPLAIN: CIGARETTES, CIGARS, PIPE ETC. DO YOU USE RECREATIONAL DRUGS? YES NO ARE YOU IN A REHABILITATION PROGRAM FOR THIS? YES NO DO YOU DRINK ALCOHOL? YES NO IF YES HOW OFTEN? ARE YOU PREGNANT? YES NO ARE YOU NURSING? YES NO EMPLOYED: YES NO EMPLOYER: OCCUPATION: (if student please specify which school you attend) SPORTS/ACTIVITIES/EXERCISE REGIMEN NUMBER OF HOURS SPENT ON YOUR FEET: STEEL TIPPED BOOTS: YES NO PRIMARY CARE PHYSICIAN: DOCTORS NAME CITY STATE DATE LAST SEEN BY YOUR PRIMARY CARE PHYSICIAN: / / ENDOCRINOLOGIST: YES NO ENDOCRINOLOGIST S NAME CITY STATE CARDIOLOGIST: YES NO CARDIOLOGIST S NAME CITY STATE PHARMACY: NAME CITY STATE WHAT IS THE REASON FOR YOUR VISIT TODAY? HOW DID YOU HEAR ABOUT OUR OFFICE? MEDICAL HISTORY: WHAT WAS THE DATE OF YOUR LAST TETANUS SHOT? HAVE YOU HAD ANY PRIOR FOOT SURGERY? YES NO Page 1
If yes, please list type and date of surgery: Date HAVE YOU HAD ANY OTHER SURGERY ON YOUR BODY? YES NO If yes, please list type and date of surgery: Date DO YOU USE ANY ASSISTIVE DEVICES? YES NO If yes, please list check off which ones: Walker? Wheelchair? Cane? Braces? Crutches? FAMILY HISTORY: PLEASE LIST YOUR RELATIONSHIP TO THE FAMILY MEMBER WHO HAS HAD ANY OF THE FOLLOWING: ARTHRITIS YES NO BLEEDING DISORDERS YES NO CANCER YES NO DIABETES YES NO FOOT DEFORMITIES YES NO HEART DISEASE YES NO HYPERTENSION YES NO OSTEOPOROSIS YES NO STROKE YES NO ARE YOU BEING TREATED FOR OR HAVE BEEN TREATED FOR ANY OF THE FOLLOWING: AMPUTATION YES NO ANEMIA YES NO ARTHRITIS YES NO ASTHMA YES NO BACK PAIN YES NO Page 2
Spinal Stenosis? Degenerative Disc Disease? Level? BLOOD CLOT/ BLEEDING DISORDER YES NO BUNION YES NO CANCER OR TUMOR YES NO TYPE: YEAR CIRCULATION PROBLEMS YES NO LAST DOPPLER EXAM DIABETES YES NO AGE OF ONSET Last Blood Sugar # / A1C Insulin Dependent or Non-Insulin Dependent (PLEASE CIRCLE ONE) EPILEPSY YES NO ENVIRONMENTAL ALLERGIES YES NO GAIT MALFUNCTION YES NO GOUT YES NO GERD YES NO HEART ATTACK YES NO IF YES, WHAT YEAR? Congestive Heart Failure Pacemaker Defibrillator HEPATITIS YES NO Hepatitis A, B or C? Counts HIGH CHOLESTEROL YES NO HIV / AIDS YES NO Counts CD4 Count HYPERTENSION YES NO KIDNEY PROBLEMS YES NO Chronic? Dialysis? Transplant? Kidney Stones? LIVER DISEASE YES NO LUNG DISEASE YES NO NEUROLOGICAL DISORDERS YES NO Alzheimer s Disease? NEUROPATHY YES NO OSTEOPOROSIS YES NO OSTEOPENIA YES NO PRIOR FRACTURE/ SPRAIN YES NO PSYCHIATRIC DISORDER YES NO Anxiety? Depression? RAYNAUD S DISEASE YES NO Page 3
SEASONAL ALLERGIES YES NO STOMACH ULCER YES NO STROKE YES NO Year? THYROID DISEASE YES NO Hyperthyroidism or Hypothyroidism (PLEASE CIRCLE ONE) TUBERCULOSIS YES NO ULCER/WOUND YES NO Location on body? VISION PROBLEMS YES NO Macular Degeneration? Cataracts? Glaucoma? Retinopathy? ARE YOU ALLERGIC TO OR HAVE YOU EVER REACTED TO ANY OF THE FOLLOWING: ANTIBIOTICS / PENICILLIN YES NO IODINE YES NO ASPIRIN YES NO LATEX YES NO BAND AIDS / TAPE YES NO LIDOCAINE/NOVACANE YES NO CODEINE YES NO RADIOGRAPHIC CONTRAST / DYE YES NO GENERAL ANESTHESIA YES NO SULFA DRUGS YES NO Other not listed? Page 4
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW Bangor Podiatry, L.L.C. MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Bangor Podiatry, L.L.C. is required by law to maintain the privacy of your protected health information. This information consists of all records related to health, including demographic information, either created by Bangor Podiatry, L.L.C. or received by Bangor Podiatry, L.L.C. from other healthcare practices. We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties and privacy practices are described in this Notice. Bangor Podiatry, L.L.C. will abide by the terms of this Notice or the Notice currently in effect at the time of use or disclosure of your protected health information. Bangor Podiatry, L.L.C. reserves the right to change the terms of this Notice and to make any new provisions effective for all protected health information we maintain. Patients will be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at any time. Uses and Disclosures of Your Protected Health Information not requiring Your Consent Bangor Podiatry, L.L.C. may use and disclose your protected health information, without your written consent or authorization, for certain treatment, procedures and healthcare operations. There are certain restrictions on uses and disclosure of treatment records, which include registration and all other records concerning individuals who are receiving, or who at any time have received services for mental illness, developmental disabilities, alcoholism, or drug dependence, and are also restrictions on disclosing HIV test results. Treatment may include: Providing, coordinating, or managing healthcare and related services by one or more healthcare providers Consultations between healthcare providers concerning a patient Referrals to other providers for treatment Referrals to nursing homes, foster care homes, or home health agencies For example, Bangor Podiatry, L.L.C. may determine that you require the services of a specialist. In referring you to another doctor, Bangor Podiatry L.L.C. may share or transfer your healthcare information to that doctor. Payment activities may include: Activities undertaken by Bangor Podiatry, L.L.C. to obtain reimbursement for services provided to you Determining your eligibility for benefits or health insurance coverage Managing claims and contacting your insurance company regarding payment Collection activities to obtain payment for services provided to you Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverage under health plan, appropriateness of care, or justification or charges Obtaining pre- certification and pre- authorization of services to be provided to you For example, Bangor Podiatry, L.L.C. will submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and the services provided to you. Healthcare operations may include: Contacting healthcare providers and patients with information about treatment alternatives Conducting quality assessment and improvement activities Conducting outcomes evaluation and development of clinical guidelines Protocol development, case management, or care coordination Conducting or arranging for medical review, legal services, and auditing functions For example, Bangor Podiatry, L.L.C. may use your diagnosis, treatment, and outcome information to measure the quality of the services that we provide and assess the effectiveness of your treatment when compared to patients in similar situations. Bangor Podiatry, L.L.C. may contact you, by telephone or mail, to provide appointment reminders. You must notify us if you do not wish to receive appointment reminders. We may not disclose your protected health information to family members or friends who may be involved with your treatment or care without your written permission. Health information may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of an incomprehensive adult; the healthcare agent designated in an incapacitated patient s healthcare power of attorney; or the personal representative or spouse of a deceased person. There are additional situations when Bangor Podiatry, L.L.C. is permitted or required to use or disclose your protected health information without your permission or authorization. Examples include the following: As permitted or required by law: In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement, officials or government agencies. For example, we may have to report abuse, neglect, domestic violence, or certain physical injuries. We are required to report gunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe the wound occurred as a result of the crime. Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on the premises. For public health activities: We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority or authorities of the law, upon receipt of written request from that agency. We are required to report positive HIV test results to the state epidemiologist. We may disclose HIV test results to other providers or persons when there has been or will be risk of exposure. We may report to the state epidemiology. This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R. 164.520 Page 5
PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Today s Date: Patient s Name: Patient s DOB: I acknowledge that I was provided a copy of Bangor Podiatry, LLC Notice Of Privacy Practices. This notice describes how Bangor Podiatry, LLC may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information as well as the rights I may have regarding my protected health information. PATIENT/GUARDIAN SIGNATURE DATE I give my permission to leave a message on my answering machine regarding any medical related issues concerning my treatment by the doctors of Bangor Podiatry, LLC. I do not give my permission to leave a message on my answering machine concerning anything related to my treatment by the doctors of Bangor Podiatry, LLC. I authorize the doctors and staff of Bangor Podiatry, LLC to discuss the details of my treatment/condition in person or by telephone with the following individuals only: 1. Phone Relationship 2. Phone Relationship 3. Phone Relationship PATIENT/GUARDIAN SIGNATURE DATE Page 6