Medical and Personal History

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1 Medical and Personal History Patient Name: Date: DOB: SEX: M / F Race: For what reason are you here today? Please check conditions which you have had AND dates conditions started: GENERAL HEENT LYMPHATIC / HEMATOLOGIC Serious Infections Glaucoma Thyroid Goiter (e.g. pneumonia) Allergies hay fever Over Active Thyroid Diabetes Mellitus Frequent Ear Infections Under Active Thyroid Rheumatic Fever Frequent Sinus Infections Transfusions HIV Infection Anemia Respiratory Cancer (where?) Asthma GI / GU CVS Emphysema Stomach Ulcers High Blood Pressure Blood Clots in Lungs Ulcerative Colitis Congestive Heart Failure Sleep Apnea Crohns Disease Heart Murmur Bleeding from Intestines Heart Valve Disease MUSCULOSKELETAL/ Diverticulitis Angina EXTREMITIES Colon Polyps Heart Attack Osteoporosis Irritable Bowel Disease High Cholesterol Rheumatoid Arthritis Hepatitis Abnormal Heart Rhythm Degenerative Joint Disease Cirrhosis of the Liver Blood Clots in Veins Fibromyalgia Liver Failure Blocked Arteries in Neck Neck Pain (herniated disc) Pancreatitis Blocked Arteries in Legs Back Pain (herniated disc) Gallstones Doctor s Notes: Kidney Stones Kidney Failure Prostate Disease Endometrosis Sex Transmitted Infection SKIN / BREAST Acne Eczema Psoriasis Fibrocystic Breast Disease NEUROLOGIC / PSYCHIATRIC Chronic Vertigo (Meniere s) Peripheral Nerve Disease Migraine Headaches Stroke Multiple Sclerosis Depression Anxiety Please indicate when you last had any of the following surgeries. YEAR YEAR YEAR YEAR Angioplasty Trauma Related Surgery Stomach Surgery Carotid Artery Surgery Back or Neck Surgery Inguinal Hernia Other Vascular Surgery Hip Sergery Colonoscopy Coronary Bypass Surgery Knee Surgery Gallbladder Chest/ Lung Surgery Carpal Tunnel Surgery Appendectomy Tonsillectomy Sinus Surgery Prostate Surgery Neurosurgery Ear Surgery Bladder Surgery Doctor s Notes: Tubal Ligation C-Section Hysterectomy Ovary Removed Breast Surgery Thyroid Surgery Other Please indicate when you last had any of the following preventative tests or services. YEAR YEAR YEAR YEAR Cardiac Angiogram Stress Test Echocardiogram Chest X-ray EKG Flu Vaccine Pneumonia Vaccine Tetanus Vaccine Hepatitis Vaccine Bone Density Test Prostate Cancer Blood Test Rectal Exam Colon Cancer Stool Test Flexible Sigmoidoscopy Barium Enema Mammogram / Breast Exam Pap Smear Date of Last Physical Exam Other Doctor s Notes: DATABASE TOOL

2 Please list any allergies or intolerance to drugs or other substances, and describe reaction: Please list the medications currently taken, their dosages, and how many times per day you take them. FAMILY MEDICAL HISTORY Please check or list any major illness in your family and indicate who. (Mother, Father, Brother, Sister or Children) Turberculosis Emphysema Heart Disease High Blood Pressure Osterporosis Notes: Diabetes Mellitus Thyroid Disease Anemia Hemophillia Kidney Disease Epilepsy Neurological Disorder Liver Disease Breast Cancer Ovarian Cancer Colon Cancer Prostate Cancer PERSONAL INFORMATION Please write in or circle the information that applies to you: Occupation: Education primary secondary college post grad doctorate Sexuality heterosexual homosexual bisexual transsexual Tobacco never / past/ active cigarette / cigar / pipe snuff / dip / chewing Start Stop packs per day Doctor s Notes: Marital Status single married divorced widowed seperated Alcohol never / past/ active liquor / wine / beer drinks per day / week / month AA / Alcohol Rehab Living Status alone with spouse with parents assisted living nursing home Diet none low fat low chol. low carbo. vegetarian Exercise none walking aerobics weightlifting days / wk Illicit Drugs never / past/ active cocaine / marijuana heroin / amphetamine barbiturate / LSD / PCP IV Drug Abuse / Drug Rehab Alternative Medicine holistic chlropractic homepathy acupuncture herbal Caffeine never / past/ active coffee / tea / soda cans / cups per day

3 Chart Update Name: Contact Number: Date: DOB: 1. Do you experience any of the following symptoms: running nose, itchy nose, stuffy nose, itchy and/ or watery eyes, or frequent sneezing? If you do, you may have allergies. Is your medical history consistant with the symptoms above? Yes No 2. Overall what is the severity of your allergy symptoms? Mild Moderate Severe 3. Are your allergy symptoms present (please circle) Rarely Seasonally (e.g. Summer/Spring only) ** 4. Please circle the symptoms you suffer from and then circle the severity of the symptom(s). a. Stuffy Nose Mild* Moderate ** Severe *** b. Runny Nose Mild* Moderate ** Severe *** c. Itchy Eyes Mild* Moderate ** Severe *** d. Watery Eyes Mild* Moderate ** Severe *** e. Itchy Throat Mild* Moderate ** Severe *** f. Sneezing Mild* Moderate ** Severe *** 5. How often do you take prescription or over-the-counter medications for your allergies? Not at all * Sometimes ** Frequently *** 6. Do you suffer from side effects such as dry mouth, drowsiness, or other effects? Not at all * Sometimes ** Frequently *** 7. Would you like to speak to someone about new treatment for your allergy symptoms? Yes No

4 GUARANTOR INFORMATION: (List person or insured name responsible for bill -use full legal name, no nicknames) Relationship of Guarantor to Patient: Self Spouse Parent Other Last Name, First: Social Security # Street Address: Zip Code * Employer Name: INSURANCE INFORMATION: (Please allow receptionist to photocopy your insurance ID cards) IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS PRIMARY INSURANCE Plan Name: Insured s Social Security #: * Insured s Name: * Insured s Date of Birth: * Policy / ID #: * Group #: * Eff Date: SECONDARY INSURANCE Plan Name: Insured s Social Security #: * Insured s Name: * Insured s Date of Birth: * Policy / ID #: * Group #: * Eff Date: Claims Address & Phone: * REQUIRED FIELDS - PLEASE COMPLETE FOR BILLING * * ATTACH COPY OF INSURANCE CARDS * Confidential Proprietary Informaiton New Patient Additional Page July 2013

5 TEXAS HEALTH PHYSICIANS GROUP PATIENT REGISTRATION FORM DISCLOSURES & CONSENTS Patient Name: Last Name First Name Date of Birth: ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize direct payment of my insurance benefits to Texas Health Physicians Group or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Texas Health Physicians Group is unable to collect from my insurance carrier for whatever reason. MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my, or my dependent's records that these programs may request. I hereby direct that payment of my, or my dependent's authorized benefits be made directly to Texas Health Physicians Group or the physician on my behalf. AUTHORIZED TO RELEASE NON-PUBLIC PERSONAL INFORMATION: I certify that I have read and been offered a copy of the Texas Health Physicians Group. "HIPAA Notice of Privacy Practices". I hereby authorize Texas Health Physicians Group, or the physician individually to release any of my, or my dependent's medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. AUTHORIZATION TO MAIL, CALL OR I certify that I understand the privacy risks of the mail, phone calls and . I hereby authorize a Texas Health Physicians Group representative or my physician to mail, call or me with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, and diagnostic test results. I understand that I have the right to rescind this authorization at any time by notifying Texas Health Physicians Group to that effect in writing. LAB/X-RAY/DIAGNOSTIC SERVICES: I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason. CONSENT TO TREATMENT: I hereby consent to evaluation, testing, and treatment as directed by my Texas Health Physicians Group physician or those under his/her supervision. PATIENT SIGNATURE: DATE: GUARANTOR SIGNATURE: DATE: (If different from patient) GUARANTOR NAME (Please print): Confidential Proprietary Information New Patient Registration Packet August 2011

6 FINANCIAL RESPONSIBILITY AGREEMENT Patient Name: Last Name First Name Date of Birth: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any medical service or visit, preventative exam or physical, lab testing, x-ray, EKG, and any other screening service or diagnostic testing ordered by the physician or the physician's staff. I understand and agree it is my responsibility and not the responsibility of the physician or the physicians' staff to know if my insurance will pay for any medical service I receive. I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amounts, usual and customary limit, or any other type of benefit limitation for the medical services I receive. I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible for all charges. I understand and agree it is my responsibility to know if my PCP (primary care physician) choice has been processed by my insurance company or plan. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payment. Signature: (Please sign here - Patient or Responsible Party) Date: Responsible Party Name: (Please print name of Responsibility Party if different from Patient) Confidential Proprietary Information New Patient Registration Packet August 2011

7 DISCLOSURE REGARDING ANCILLARY SERVICE/RESEARCH PROGRAMS Ancillary service Your physician may refer you to one or more "Ancillary Services" in connection with your medical care. An "Ancillary Service" is a service relating to your medical care or treatment. The following types of services are Ancillary Services: Magnetic Resonance Imaging (MRI) Mammography Ultrasound Computer Tomography (CT) Position Emission Tomography (PET) X-Ray Infusion Therapy Bone Density Imaging Nuclear Imaging Laboratory Durable Medical Equipment(DME) Echo Cardiograph Sleep Therapy Audiology Your physician may have an economic interest in or business relationship with the company or person who provides the Ancillary Services. You are not obligated to use the provider that your physician refers to. You are free to use any provider you choose. Research Programs Your physician may ask if you would like to participate in a clinical trial or other research program. These programs may be sponsored by a drug company or may be part of a government research program. Your physician may be compensated for services rendered in connection with these programs. You are not obligated to participate in any research program and your permission will be obtained prior to your participating in a program your physician believes may be appropriate for you. Please feel free to ask your physician if you have any questions about a particular Ancillary Service or research Program. Printed Patient Name Patient Signature Date

8 Preferred Imaging 1614 Scripture, Suite 2 Denton, TX I-35 E, Suite C-105 Corinth, TX (940) Touchstone Imaging Woodhill Square 1100 Dallas Drive, Suite 114 Denton, TX (940) Other Touchstone Imaging locations in Lewisville, Flower Mound, Dallas, Garland, Richardson and Plano Clear Sky MRI 3188 Los Colinas Denton, TX (940) Texas Oncology Denton 2900 North I-35, Suite 100 Denton, TX (940) Corinth PET Imaging 4851 S. I-35 E, Suite 101 Corinth, TX (940) Lake Vista Cancer Center 2790 Lake Vista Dr. Lewisville, TX (972)

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