Patient Information Packet Date:

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Transcription:

Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email: Marital Status: Spuse Name: Emergency Cntact Name: Phne: Primary Care Physician: Phne r Address: Please Tell Us Hw Did Yu Find Us? Dctr Referral (Dr. ) Facebk Friend r Family Pearland s Best Cupn Bk Ggle Our Website Magazine Ad Other Ad Mailed Pstcard Event (ex: Senir Fest) E.R. Referral Drve by Our Office Phnebk Other: Emplyment Infrmatin Emplyer Name: Phne: Address: City: State: Zip: Emplyment Status: (Check) Full Time Part Time Unemplyed Retired Self Emplyed Insurance Infrmatin Please Check One Self Pay? (N Insurance) Insured? (Have Insurance) Please prvide a cpy f yur insurance card if applicable FOR RECORDS (OFFICE USE) See attached cpy f insurance card fr insurance infrmatin Primary Insurance: Plicy Number: Secndary Insurance: Plicy Number: Medicaid Number: Reference Number: Primary Care Dctr: Did They Refer Yu? Yes N

Health Histry Infrmatin Patient Name: DOB: Yur Symptms: Check all symptms that apply t yu PLEASE read carefully! What are yu here t take care f tday? Weight Lss / Gain Chills /Fevers Fatigue / Lack f Energy Dizziness Insmnia Seizure Frequent Headache Cugh Prductin f Sputum Chest Pains Wheezing Dry Skin Itchy Skin Hepatitis Jaundice Bld Transfusin Cirrhsis Nausea Vmitting Heart burn / Indigestin Excessive Salivatin Lss f Appetite Fullness in Stmach Vmiting f Bld Abdminal Cramps Pain after eating Cnstipatin Diarrhea Change f Stl Width/Diameter Rectal Itching / Pain Hemrrhid Painful Bwel Mvement Ribbn-Like Stl Diarrhea After Eating Visible Bld in Stl Incmplete Bwel Mvement Lw Thyrid Muscle Pain Stiffness f Jints Excessive Burping Bad Breath Harseness f Vice Palpitatin f Heart Shrtness f Breath Heart Murmur Abnrmal Heart Rhythm High Bld Pressure / Heart Issues Mental Disrders Depressin Anxiety Frgetfulness Unusual Early Mrning Awakening Painful Urinatin Incmplete Urinatin Frequent Urinatin Prblems with Kidney Diabetes / Bld Sugar Issues Mucus / Slime in Stl Dark / Tarry Stl Abdminal Swelling Excessive Gas / Blating Dryness f Muth Very Imprtant: Please answer Yes/N t the fllwing Yes N 1. Have yu ever had bld pressure / heart issues? 2. T the best f yur knwledge, d yu have any allergies t anything? (If yes, please list belw) 3. Have yu ever had any peratins during yur life? Please explain belw: 4. Please check if yu take any medicatins, injectins, r pills fr the fllwing: Heart Kidney Lungs Diabetes Eye Bld Pressure 5. D yu smke? (If s, hw many packs per day? ) 6. D yu drink? (If s, hw frequently? )

Medical Release Frm Authrizatin Ntice Release t 109 Parking Way Lake Jacksn, TX 77566 Fax: (979)292-0488 109 Parking Way Lake Jacksn, TX 77566 Fax: (979)292-0488 109 Parking Way Lake Jacksn, TX 77566 Fax: (979)292-0488

Medical Infrmatin Patient Name: DOB: Tday s Date: Pharmacy Name: Pharmacy Lcatin: List f Current Medicatins & Dsages

Acknwledgement f Privacy Practice Ntice

Tll Free: (888) 292-0010 www.yourgicenter.cm This frm is legally required; we aplgize fr the extra paperwrk. Patient Name: Date f Birth: Date: Are yu current n yur flu sht? Yes N Have yu had yur pneumnia sht in the last 5 years? Yes N Fr Wmen Only 1. Are yu up t date n mammgram? Yes N 2. D yu have prblems with urinary incntinence? Yes N 3. D yu have steprsis? Yes N 4. Have yu had bne density tests? Yes N

Tll Free: (888) 292-0100 Website: Facebk: Email: hell@yurgicenter.cm Patient Name: Date f Birth (DOB): Tell us abut yur family histry Sn alive and well? Yes N Sn alive with prblems? Yes N Sn deceased? Yes N Daughter alive and well? Yes N Daughter alive with prblems? Yes N Daughter deceased? Yes N Mther alive and well? Yes N Mther alive with prblems? Yes N Mther deceased? Yes N Father alive and well? Yes N Father alive with prblems? Yes N Father deceased? Yes N

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