Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/ ID# : Name on Card: Contact Information: Date of Birth: Phone: Soc Security #: Email:_ Effective Date: Date of Birth / / **SECONDARY INSURANCE** Sex: M F Insurance Company: Claim Address:_ Soc Security #: City/state/Zip: Group #: **Emergency Contact Information** Policy/ ID# : Name_ Name on Card:_ Phone_ Date of Birth: Relationship: Soc Security #:_ Effective Date:_ Name:_ **Other Physicians** Phone:_ Name: Relationship: Phone: Fax: Specialty Responsible Party Billing address (If not same as above) Name: Name: Phone: Street: Fax: Specialty Town/State/Zip: Page 1!
Past Medical History Have you ever been Hospitalized? Yes No If yes, why? Have you ever been treated for Hepatitis A,B, or C Yes No If yes, which? Have you been vaccinated for Hepatitis B? Yes No If yes, date complicated: Have you been vaccinated for Hepatitis A? Yes No If yes, date complicated: Last Tuberculosis (TB) Screening? Result of screening: Positive Negative If positive TB screen, date of last chest x-ray: Have you ever had a sexually Transmitted Disease? Yes No Result of Chest Xray: Positive Negative Diagnosis: Which of the following conditions are you currently being treated for or diagnosed with in the past? (Please check) Heart disease / Murmur / Angina High cholesterol High blood pressure Low blood pressure Anemia or blood problems Swollen Heartburn (reflux) Shortness of breath Asthma Sinus problems Seasonal allergies Tonsillitis Ear problems Lung problems / cough Eye disorder / Glaucoma Seizures Head aches / Migraines Neurological problems Depression / Anxiety Psychiatric care Stroke Diabetes Kidney / Bladder problems Liver problems / Hepatitis Arthritis Cancer Ulcers/colitis Thyroid problems Please Describe any current or past medical treatment not listed above Page 2!
Please list your past surgeries Allergies Are you Allergic to penicillin or other drugs? Yes No Please list: Have you ever had to use an Epinephrine Pen? Yes No If Yes, date administered: Medications: (PLEASE LIST ALL MEDICATIONS) Social and Preventive History Do you currently smoke or chew tobacco? Yes No If no, have you in past? Yes No Do you drink alcohol, beer, or wine? Yes No If no, have you in past? Yes No Do you currently drink coffee or tea? Yes No If yes, how many cups per day? Do you wear a helmet when riding bike? Yes No Do you exercise weekly? Yes No Do you wear seatbelt when driving? Yes No Family History Living Age (or age of death) List of serious illness Mother Yes No Father Yes No Sisters Yes No Yes No Page 3!
Brothers Yes No Yes No Has any member of your family (including children and parents) had any of the following illness: Illness Anemia or blood disorder Cancer Diabetes Glaucoma Heart Disease High Blood Pressure HIV disease/ AIDS Mental Status/ Depression Stroke Other serious illness Which family member(s) Females: Do you routinely see OBGYN? Yes No How many times have you been pregnant? Date of last Pap Smear: Have you had an abnormal Pap smear? Yes No Diagnosis: Date of last Mammogram: Mammogram results: Have you ever had a breast biopsy? Yes No Biopsy results: By signing below, I certify that to the best of my knowledge all the information I have furnished on this form is complete, true, and accurate. I hereby give consent for medical treatment. I also give consent for Clinical Care Management conducted by nursing and provider staff. I have read the comprehensive patient information and I agree, as per company guidelines, Medical House Calls of the North Fork reserves the right to begin the immediate discharge of any patient if any of the following occur; abuse including physical and/or verbal, sexual innuendo, threatening communications, or assault by the patient or any family members. Patient/ Legal Guardian Signature Date: Page 4!
PATIENT MEDICAL INFORMATION RELEASE Patient Name: DOB: Address: Medical House Calls of the North Fork is authorized to ( ) Furnish ( ) Receive (check which applies) Medical records to/from any Hospital, Facility, or Doctor OR Specific Recipient/ Discloser: I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS ( ) I GIVE PERMISSION TO THE RELEASE OF MY MEDICAL RECORDS including information and records or copies of records relating to the history, diagnosis, treatment, or services rendered to me in connection with any condition or disease. This includes permission to release POTENTIALLY SENSITIVE INFORMATION which may include information concerning my treatment of mental illness, Human Immunodeficiency Virus (HIV), alcoholism, drug use/ dependency, venereal disease, sexual assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies, psychologists, if any ( ) I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described below. I release Medical House Calls of the North Fork and the Recipient/ Discloser listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Medical House Calls of the North Fork, provided that I do so in writing and to the extent that you already disclosed the information in reliance on this authorization. This authorization expires / / (optional) if no expiration date is given, then this authorization shall remain in effect for 12 months from date of signature. Patient Signature (Legal Representative) Date Page 5!