COMPREHENSIVE WOMEN S CENTER
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- Mary Carroll
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1 COMPREHENSIVE WOMEN S CENTER (L to R) Anna Bobba, MD, Susan Scanlon, MD, NCMP Kathryn M. Ray, MD, Mary S. Farhi, MD, MPH, NCMP We are very pleased that you have selected our practice. Our mission is to enhance and extend women s lives by providing the highest quality obstetrics and gynecologic services in a caring manner. In preparation for your upcoming visit, please complete the attached forms and bring all forms and your insurance card to your appointment. In order to ensure that our records are updated, it is necessary for us to request these forms once per calendar year. If you have any questions when completing these forms, please contact us at the numbers below. We look forward to seeing you soon. Wheeling Office Hoffman Estates Office 1083 Lake Cook Road 1555 Barrington Rd., Suite 4300 Wheeling, IL Doctor s Building #3 (847) Tel Hoffman Estates, IL (847) Fax (847) Tel (Intersection of Lake Cook Road and Lexington) (847) Fax 1
2 Patient Information (PLEASE PRINT) Name Date Address Home Phone City State Zip Date of Birth Age Social Security No. Marital Status S M W D Employer Work Phone Address Cell Phone Referred by? Dr. Friend Other PRIMARY INSURANCE Ins. Company Group# ID# Name of Cardholder Date of Birth Social Security No. Is Your Insurance through Your Employer? Yes No Effective Date / / (circle one) Employer Relationship to Insured SECONDARY INSURANCE Ins. Company Group# ID# Is Your Secondary Insurance through Your Husband Parent (circle one) Name of Cardholder Date of Birth Social Security No. Employer Relationship to Insured Insurance Effective Date / / EMERGENCY INFORMATION Name Home Phone Relationship Work Phone Non-Family Member Contact Signature Date 2
3 I authorize release of information to insurance carriers and/or health care providers as may be necessary to file a claim or facilitate my health care. I assign payment of benefits to CWC and understand that I am financially responsible for any balance not covered by my insurance carrier. Patient due balances are due and payable within 30 days of receipt of statement. I agree to pay all collection costs which are incurred if my account is referred to an outside collection agency. If CWC refers the collection of the balance to a lawyer, I agree to pay all lawyers fees which are incurred plus all court costs. This form is valid for one year unless rescinded or otherwise modified by you. Signature Date Credit Card Information for No Show/No Call Cancellation Policy Name on Credit Card VISA MASTERCARD DISCOVER (please circle one) Credit Card Number Expiration Date 3 digit code I wish to be contacted in the following manner (check all that apply) Home Telephone # Written Communication O.K. to leave message with detailed information O.K. to mail to my home address Leave message with call-back number only O.K. to fax to Cell Phone Work Phone O.K. to leave message with detailed information Leave message with call-back number only The doctors and staff of CWC may only speak with anyone (including your spouse) regarding your healthcare if you give us written consent. The following statement if optional: I give CWC, its doctors and staff permission to speak with, my Regarding my (check one or both) medical records, tests, and progress financial and/ or insurance information PLEASE PRINT NAME (DATE) SIGNATURE OF PATIENT/RESPONSIBLE PARTY (DATE) SIGNATURE OF ADULT/GUARDIAN WITH MINOR (DATE) 3
4 Patient Name CONFIDENTIAL PERSONAL HEALTH HISTORY MEDICAL HISTORY MEDICATIONS (Please List) Do you or did you ever have any of the following? Check ( ) if yes. Dates Anemia Diabetes High Blood Pressure Cigarettes Thyroid Disease Packs Per Day How Long? Tumor of any kind How much alcohol do you consume? Cancer Syphilis or gonorrhea Drugs Convulsions or epilepsy Frequent or severe headaches SURGICAL HISTORY Blood Clots or phlebitis Asthma Persistent Cough Rheumatic Fever Heart Disease or Murmur Blood Transfusion Rapid or Irregular Heartbeat FAMILY HISTORY Chest Pain Have your grandparents, parents, uncles, aunts, German Measles brothers, sisters or children ever been treated Frequent or severe abdominal pain for: Ulcer Disease Check ( ) if yes. Gall Bladder Disease Yellow jaundice or hepatitis Explanation & Dates Bladder or kidney disease Cancer Arthritis Blood Disease Varicose Veins Tuberculosis Easy Bruisability Heart Disease Tuberculosis Kidney Disease Skin Disease Lung Disease Depression or Anxiety Epilepsy Unusual Hair Growth Diabetes Recent Weight Change Nervous Disorders High Cholesterol Muscular Disorders Other Diseases Birth Defects History of Twins 4
5 CONFIDENTIAL PERSONAL GYNECOLOGY HISTORY MENSES Last Menstrual Period Was it a normal period? Age at first period At present, periods are Regular Irregular Number of days between periods Duration of periods ABNORMAL UTERINE BLEEDING My periods are prolonged (more than 7 days). Prior treatment? Yes No I have excessive flow. If yes, please check all that apply: My periods are greater than 35 days apart. Birth Control Pills (from beginning of one cycle to the next) Premarin I have been embarrassed and/or forced to Provera/Depo-Provera leave a situation due to heavy bleeding. Endometrial Ablation I have missed work and/or other Hysterectomy responsibilities due to my heavy periods. I have uterine fibroids. PAP SMEARS Date of last pap smear Was it a normal pap smear? Yes No Have you ever had an abnormal pap smear in the past? Yes No If Yes: What was the date (approximately)? Were you treated? Yes No What was the treatment? PREGNANCY Del. Date Birth Wt. Sex Living Y/N Vaginal C/S Early or late delivery? Complications? CONTRACEPTION What contraception do you use currently? Birth Control Pills Depo-Provera/Lunelle Condoms Diaphram IUD Tubal Ligation/Vasectomy Natural Family Planning Other What contraception have you used in the past? Birth Control Pills Depo-Provera/Lunelle Condoms Diaphram IUD Tubal Ligation/Vasectomy Natural Family Planning Norplant Other 5
6 CONFIDENTIAL PERSONAL GYNECOLOGY HISTORY Page 2 PELVIC PAIN I experience pain with intercourse. Prior treatment? Yes No I experience moderate to severe pain with If yes, please check all that apply: my periods. Birth Control Pills I am missing days from work due to the Laser surgery severity of my pain. Laparoscopy I have significant pelvic pain not related Hysterectomy to my period or intercourse. Pain medication I have a history of endometriosis. SEXUALLY TRANSMITTED DISEASES Have you ever been diagnosed with Gonorrhea Chlamydia Syphilis HIV Genital Warts Trichomonas Hepatitis Herpes Were you treated? Yes No Was your partner treated? Yes No BREAST HISTORY I do monthly self-breast exams. Prior treatment? Yes No I have annual mammograms done. If yes, please check all that apply: I have a personal history of breast cancer. Last mammogram I have a family history of breast cancer. Breast aspiration I have a history of fibrocystic breast disease. Breast biopsy Breast surgery Surgeon s Name MENOPAUSE (if applies to you) My periods have been irregular or absent Prior treatment? Yes No over the last several months. If yes, please check all that apply: I am experiencing hot flashes and/or Endometrial biopsy night sweats. Hormone Replacement Therapy I have vaginal dryness and/or experience Soy Protein pain with intercourse. Vitamin E Since going through menopause, I have Other experienced spotting or vaginal bleeding. 6
7 CONFIDENTIAL PERSONAL GYNECOLOGY HISTORY Page 3 INCONTINENCE (if applies to you) I experience discomfort with urination. Prior treatment? Yes No I have trouble making it to the bathroom If yes, please check all that apply: without an accident. Medication(s) I often feel the urge to urinate even when Incontinence Ring the bladder is not full. Weighted Vaginal Cones I leak urine when I cough or sneeze. Pelvic Muscle Exercises (Kegels) I leak urine when I exercise or have intercourse. Biofeedback I leak urine when I hear the sound of running water. Surgery OSTEOPOROSIS I am in menopause. Prior treatment? Yes No I am not currently or have never taken If yes, please check all that apply: estrogen. Calcium I am Caucasian, Hispanic, Asian or Native Vitamin D American. Weight Bearing Exercise I have a family history of osteoporosis. Hormone Replacement Therapy I drink greater than 3 cups of coffee per day. Fosomax I do not exercise regularly. Other I am a smoker. Since the age of 45, I have had a broken bone at the hip, rib, and/or wrist. I have been treated for and/or been told that I have rheumatoid arthritis. 7
8 M. Susan Scanlon, MD Mary S. Farhi, MD, MPH - Kathryn M. Ray, MD Stephen F. Gladdin, MD Anna Bobba, MD Date: Patient Name: Please check one (1) of the following: Are you here for your annual well woman/preventive exam and pap smear? or Are you here for treatment of specific medical symptoms or problems? Please check yes or no below: Do you desire STD (sexually transmitted disease) testing? Yes No Your insurance plan or policy determines your medical coverage. Please become knowledgeable about your benefits. Our responsibility is to submit a claim which reflects the services performed in this office based on coding guidelines and regulations. Patient Signature Date 1555 Barrington Rd., Suite Lake Cook Road Wheeling, IL Hoffman Estates, IL (847) Tel (847) Tel (847) Fax (847) Fax 8
9 M. Susan Scanlon, MD Mary S. Farhi, MD, MPH - Kathryn M. Ray, MD Stephen F. Gladdin, MD Anna Bobba, MD Notice of Privacy Practice Receipt I acknowledge that I was provided with the Notice of Privacy Practices of the Medical Practice named at the top of this page. Print Name of Patient: **Signature of Patient: Date: Patient s Date of Birth: For Personal Representative of the Patient (if applicable) Print Name of Personal Representative: Describe Personal Representative: Relationship (parent, guardian, etc.): Signature of Personal Representative: Date: Signature of Practice Employee Date 1555 Barrington Rd., Suite Lake Cook Road Wheeling, IL Hoffman Estates, IL (847) Tel (847) Tel (847) Fax (847) Fax 9
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Welcome to Denver Arthritis Clinic!
Welcome to Denver Arthritis Clinic! We would like to introduce your to our DAC ehealth Portal with the convenience of 24-hour-a-day access. DAC ehealth Portal is a unique personalized service that allows
Patient History Form
Patient History Form Today s Date / / Patient Name: Age: Date of Birth / / MRN # Patient Mailing Address: Hand Preference: Right Left Both Race/Ethnicity(Optional): Referring Physician and Address: Primary
Known Donor Questionnaire
Known Donor Questionnaire Your donor s answers to these questions will provide you with a wealth of information about his health. You ll probably need assistance from a health care provider to interpret
Fax or mail records to: San Diego Center for GYN Oncology. 955 Boardwalk St. Sui Murrieta Ca 92562 San Marcos Ca 92078 Fax: 760 471-0211
1. Thank you for choosing San Diego Center for GYN Oncology for your care. This packet contains information you will need for your appointment. Please review this information closely and contact our office
PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression
Name: Review of Systems DOB: / / For staff: place patient label here. Check here if no symptoms. Check concerns below only if you have experienced symptoms recently. General loss of appetite abnormal weight
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION
Trinity Dental Phone: 260-582-2607 900 S. Main Street, Kendallville, IN 46755 trinitydental@trinitydentaloffice.com PATIENT INFORMATION Welcome to our office. We appreciate the confidence you place with
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Patient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:
DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: - - Email: Address: City: State: Zip: Sex: M F Birthdate:
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
How did you hear about our office?
PATIENT INFORMATION Patient's name Preferred name Male Female If minor, responsible party name Mailing address City State Zip Social Security Number Birth date Home phone Work phone Cell phone Email Employer
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
Yes/No. Are You ALLERGIC to any medications? Please specify:
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Rheumatology Associates of North Jersey New Data Sheet
Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient Name: Previous Name: Date of Birth: Social Security: I request and authorize to release healthcare information of the patient named above to:, FL
MICHAEL D BROOKS, DMD, MS, PLLC MICHAEL J BOWMAN, DDS, MS, PLLC PATIENT INFORMATION RECORD DENTAL INSURANCE
PATIENT INFORMATION RECORD NAME DATE DATE OF BIRTH SEX SOCIAL SECURITY HOME ADDRESS HOME PH EMAIL CITY STATE ZIP EMPLOYER OTHER PH DENTAL INSURANCE PRIMARY SUBSCRIBER NAME SOCIAL SECURITY # DATE OF BIRTH
New Patient Registration Information
New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight: