ADULT INFORMATION SHEET

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Transcription:

DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS: OCCUPATION: WORK PHONE #: SINGLE MARRIED WIDOWED SEPARATED DIVORCED SPOUSE S FULL NAME: LAST FIRST MI BIRTHDATE: SOCIAL SECURITY #: SPOUSE S PLACE OF EMPLOYMENT EMAIL: OCCUPATION WORK PHONE: HOW WOULD YOU LIKE TO BE NOTIFIED FOR APPOINTMENT CONFIRMATION? EMAIL PHONE * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** HOW DID YOU HEAR ABOUT OUR CLINIC? ** WHO IS RESPONSIBLE FOR THIS BILL? ** WHICH PHYSICIAN REQUESTED THIS CONSULTATION? CITY/STATE ** FAMILY DOCTOR? CITY/STATE ** WHO CAN WE CONTACT IN CASE OF EMERGENCY? RELATIONSHIP: PHONE #: ** I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATIO NNECESSARY TO PROCESS ANY CLAIM FILED OR RELEASE MEDICAL RECORDS ON MY BEHALF. ** I ALSO ASSIGN ANY BENEFITS FROM MY INSURANCE COMPANY LISTED ABOVE TO THE PHYSICIAN FOR SERVICES DESCRIBED ON THE CLAIM FORM. FINANCIAL AGREEMENT: I fully understand that I am ultimately responsible for any and all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court costs, attorney fees, and any other charges incurred in the collection of any balance due. SIGNED: DATE: SPRINTPRINT 662-841-9292

PAGE 1 OF 3 PATIENT NAME: DATE OF BIRTH: NEVER SMOKER: X CURRENT SMOKER: complete below FORMER SMOKER: complete below # Packs Per Day: Year You Quit: SMOKELESS TOBACCO? # Cigarettes Per Day: # Packs Per Day Used to Smoke: How Many Years Smoking?: # Years You Smoked: DRINK ALCOHOL : NO: YES: (if yes complete below) 1. SOCIALLY 2. INFREQUENTLY 3. FREQUENTLY 1. BEER 2. LIQUOR 3. WINE # Drinks per Week # Drinks Per Month RECREATIONAL DRUG USE? Yes / No : (LIST TYPE): SURGERIES: LIST ALL SURGERY THAT THE PATIENT HAS HAD: Date of Last Flu Shot, MONTH AND YEAR: Date of Last Pneumonia Shot, MONTH AND YEAR: FAMILY (Mother, Father, Sister, Brother, Daughter, Son) MEDICAL HISTORY : (M) Mother ; (F) Father ; (S) Sister ; (B) Brother; (D) Daughter ; (SON) Son ADOPTED HISTORY UNKNOWN FOOD ALLERGY-(LIST) ALZHEIMER S ASTHMA CORONARY ARTERY DISEASE CANCER (LIST TYPE): GERD (ACID REFLUX) HEADACHES/MIGRAINES HEART DISEASE KIDNEY DISORDER SLEEP APNEA SEIZURES CHRONIC SINUS PROBLEM THYROID DISORDER ALLERGIC RHINITIS PET ALLERGY ARTHRITIS AUTISM COPD DIABETES FIBROMYALGIA HEARING LOSS HIGH BLOOD PRESSURE MENIERE S DISEASE PARKINSON S SKIN DISORDER STROKE VERTIGO (dizziness) COMPLETE NEXT 2 PAGES

PATIENT S MEDICAL CONDITIONS (NONE): PAGE 2 OF 3 ADHD ALCOHOLISM ALLERGY TESTS MILK ALLERGY PET ALLERGY ALZHEIMER S ANXIETY ASTHMA AUTISM CHEST PAIN COPD DENTAL CAVITIES DIABETES FIBROMYALGIA GERD (ACID REFLUX) HEARING LOSS HEART DISEASE HEPATITIS (Type): HIGH CHOLESTEROL IMPACTED EAR WAX IRRITABLE BOWEL SYNDROME LARYNGEAL CANCER LUPUS MIGRAINES OSTEOARTHRITIS EAR INFECTIONS, CHRONIC PARKINSON S SEIZURE DISORDER SINUS INFECTION PARAthyroid DISORDER VERTIGO (DIZZINESS) CURRENT SMOKER OTHER CONDITION- PLEASE LIST: (X ) CURRENT (X )PAST (X) CURRENT (X) PAST CANCER (LIST Type): ALLERGIC RHINITIS EGG ALLERGY PEANUT ALLERGY SEAFOOD ALLERGY ANEMIA ARTHRITIS / RHEUMATOID ARTHRITIS ATRIAL FIBRILLATION NECK PAIN CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE DEPRESSION EMPHYSEMA TOBACCO SMOKE EXPOSURE AT HOME GRAVE S DISEASE HEART ATTACK HIGH BLOOD PRESSURE HUMAN IMMUNODEFICIENCY VIRUS / HIV HIGH LIPIDS INSOMNIA KIDNEY DISORDER HOARSENESS MENIERE S DISEASE MITRAL VALVE DISORDER OSTEOPOROSIS SLEEP APNEA: CPAP or BIPAP CHRONIC SORE THROAT / TONSILLITIS SKIN DISORDER STROKE THYROID DISORDER: Nodule, HYPOthyroid, HYPERthyroid; Goiter VISUAL IMPAIRMENT: Glasses, Contacts SEXUALLY TRANSMITTED DISEASE OTHER CONDITION: COMPLETE NEXT PAGE

PAGE 3 OF 3 NAME & LOCATION OF YOUR LOCAL PHARMACY: Name of Pharmacy: Location of Pharmacy: ALLERGIC TO: LIST BELOW ALL MEDICINE THE PATIENT IS ALLERGIC TO: MEDICATION: LIST BELOW ALL MEDICINE THE PATIENT IS PRESENTLY TAKING: 1. NAME OF MEDICATION 2.DOSAGE/Milligrams 3.HOW MANY TIMES PER DAY FINAL PAGE

Ear, Nose and Throat Physicians, P.A. Consent for Treatment Patient Name: Date of Birth: Relationship to Patient: CHILDREN (FAMILY MEMBERS ONLY) PLEASE LIST ALL PERSONS THAT MAY BRING YOUR CHILD TO OUR CLINIC AND THAT WE MAY TALK TO REGARDING YOUR CHILD S CARE AND TREATMENT: (EXAMPLE: GRANDPARENTS, AUNTS/UNCLES, ETC.) ONLY PARENTS OR LEGAL GUARDIANS MAY SIGN CONSENTS FOR SURGERY OR GET COPIES OF MEDICAL RECORDS. ADULTS (FAMILY MEMBERS ONLY) PLEASE LIST ALL PERSONS WHO MAY HAVE ACCESS TO YOUR MEDICAL RECORD: SIGNATURE OF PATIENT, PARENT, OR GUARDIAN DATE

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