Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

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Transcription:

Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business Address: City: State: Zip Code: Marital Status: Spouse/Significant Other: Cell: Business/Other Phone: Email: Insurance Information Our office policy requests copies of both your insurance card(s) and picture ID Primary Insurance: Company Subscriber Name DOB Social Security # Group # Subscriber # Secondary Insurance: Company Subscriber Name DOB Social Security # Group # Subscriber # Assignment and Release I, the undersigned certify that I (or my dependent) have insurance coverage with (name of insurance companies) and assign directly to Dr. Mark Schlesinger all insurance benefits, if any, otherwise directly payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature Relationship Date Page 1 of 6

Who is your primary care physician? Who referred you to our office? Complete list of Physicians: Cardiologist Phone Neurologist Phone Orthopedic Surgeon Phone Neurosurgeon Phone RPMHx Do you have a history of: Spinal Fracture Spinal Curvature Arthritic Conditions Fibromyalgia Disc Disease Spinal Stenosis Obesity Do you have? Bowel Incontinence Bladder Incontinence Weakness/Coordination Problems Past Medical History (circle all that apply) Cardiovascular High Blood Pressure Low Blood Pressure Embolism Heart Attack Arterial Insufficiency Venous Insufficiency Respiratory Asthma Emphysema Chronic Bronchitis Frequent Pneumonia Frequent Colds Productive Cough Positive TB test Abnormal CXR Gastrointestinal Acid Reflux Ulcers Polyps Hepatitis Pancreatitis Bowel Problems Colitis Hiatal Hernia Gallbladder Problems Irritable Bowel Synd. Crohn s Disease Endocrine Obesity Hypothyroidism Diabetes Insulin Hematologic Anemia Blood Clots Neurologic Memory Problems Seizures Stroke Movement Disorders Page 2 of 6

Muscular Dystrophy Polio Neuropathy Epilepsy Migraines Chronic Headaches Psychological Nervous Breakdown Depression Anxiety Panic Disorders Claustrophobia Psychosis Alcohol Abuse Drug Abuse Genitourinary Sexual Dysfunction STD s Prostate Problems Kidney Problems Bladder Problems Chronic Infection Incontinence Musculoskeletal Fibromyalgia Rheumatoid Arthritis Osteoarthritis Osteoporosis Back Problems Neck Problems Scoliosis Cancer History Site Date of Diagnosis Chemotherapy Radiation Have you ever been tested for HIV? Y / N Have you ever been tested for Hepatitis? Y / N Have you ever had a blood transfusion? Y / N Results: Results: Dates: Are you taking any blood thinners such as Coumadin, Plavix or Ticlid? Please list all of your Medicines. Medicine Dose Starting Date Times per day As Needed Pills per day Page 3 of 6

Please list all of your allergies. (None) Medication Reaction Local Pharmacy: (Where would you like your prescriptions to be filled?) Name Phone # Address Fax # Family History Relative Condition 1 Condition 2 Condition 3 Condition 4 Father Mother Brother Sister Other Surgical History Please List All Operations: Procedure Date Surgeon Page 4 of 6

Nerve Blocks: Procedure Date Surgeon Social History Education Highest Level Completed High School College Graduate School Work History Marital Status Smoking Job: Employer: Full Time Part Time Disabled Since: Single Married Widowed Divorced Other: Never Started: Stopped: Packs per day: Alcohol Never Rarely Socially Daily # of Drinks Have you ever been treated for Alcoholism? Y / N If so, how long have you been sober? Height: Weight: Have there been any recent changes? Page 5 of 6

Please circle all that apply. ROS: Constitutional HEENT Vision loss Hearing Loss Vertigo Respiratory Cough Dyspnea Wheezing Cardiovascular Chest Pain Cyanosis Irregular heart beat Gastrointestinal Constipation Diarrhea Nausea or Vomiting Genitourinary Blood in Urine Dysuria Metabolic/Endocrine Cold Intolerance Heat Intolerance Weight changes Neuro/Psychiatric Difficulty walking Dizziness Headache Dermatologic Acne Contact allergy Rash Musculoskeletal Joint Symptoms Muscle weakness Stiffness Hematologic Bleeding Disorders Blood Clots Easy Bruising Immunologic Bee Sting Allergies Environmental Allergies Food Allergies Page 6 of 6

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