Joseph G. Magnant, MD,FACS,RPVI. Name: Date of Birth: Last First Middle Initial. Soc. Sec # Gender Marital Status : Address:
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1 ( Patient Information (Please Print) Name: Date of Birth: Last First Middle Initial Soc. Sec # Gender Marital Status : Address: City State Address: If different from above (Visitor or non-permanent Fl Resident) Home Phone: Work Phone: Cell Phone: Primary Language: Race: Emergency Contact: Emergency Phone: Primary Care MD: Referring Physician: Pharmacy: Name/location: Occupation: Employer: Employer address: Phone: HOW DID YOU HEAR ABOUT VEIN SPECIALISTS? Please circle one that most applies Billboard Friend/Relative Fl Health Care News Insurance Company Internet Search Magazine Newspaper Patient Phone Book Primary Care Physician Radio Seminar Special Event SW Fl Health & Wellness TV Vein Directory Website (Vein Specialists Other (please specify) Page 1
2 ( Patient Information (Please Print) Primary Insurance Provider : Insurer: Subscriber: Complete below if you are not subscriber Relationship: D.O.B.: Soc Sec # Gender: Plan Name: Effective Date: Policy Number: Group Number: Co Pay Specialist: Subscriber (Patient/Spouse/Parents) Subscriber Address: City: ST: Zip: Employer: _ Employer Address: City: ST: Zip: Country: Subscriber Phone # Home: Cell: Secondary Insurance Provider: Insurer: Subscriber: Complete below if you are not subscriber Relationship: D.O.B.: Soc Sec # Gender: Plan Name: Effective Date: Policy Number: Group Number: Co Pay Specialist: Subscriber (Patient/Spouse/Parents) Subscriber Address: City: ST: Zip: Employer: _ Employer Address: City: ST: Zip: Country: Subscriber Phone # Home: Cell: Page 2
3 ( Medical Information Release & Assignment of Benefits: Joseph G. Magnant, M.D., F.A.C.S is herby authorized to furnish information to insurance carriers concerning my illness and treatments, and to collect all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered or paid by insurance. I am also responsible for any Deductible, Copay and/or Co-Insurance at the time of services rendered. I certify that the information I have reported with regard to insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. I have the right to revoke this authorization at any time in writing. Patient signature: Date: Parent/Guardian Signature: Date: MEDICAL INFORMATION Reason for Today s Visit? Right Leg Left Leg Both Legs Pain in Legs Ulceration Bleeding from Veins Reticular/Blue Veins Achy/Heavy Legs Swelling in Legs Inflammation Blood Clot Restless Legs Nighttime Urination Bulging/Varicose Veins Stasis Dermatitis Spider Veins Leg Cramps at night F F Skin Discoloration/rash How Long Have You Had The Above? # of Days: #Weeks: #Months: #Years: Do you smoke?: Current Never Quit (how long): Alcohol Consumption: Never Rare Socially Daily Continued on reverse side Page 3
4 MEDICAL INFORMATION (Regarding your Legs) Please check all that apply Previous Treatments: Tylenol/Motrin/Other Compression Hose Elevation Endovenous Closure Injection Sclerotherapy Laser Sclerotherapy Stripping Varicose Vein Excision Fluid Pills Other My legs feel worse: Sitting Standing Walking Working Menstrual Cycle Pregnancy Beginning of Day End of Day Lying Down My legs feel better with: Elevation Rest Compression Hose Tylenol/Motrin/other Fluid Pills Walking Beginning of Day End of Day Other Page 4
5 ( MEDICAL INFORMATION (continued) Number of Pregnancies: Number of live births: Past Surgeries: - Please Check all that apply Appendix Arthroscopy Back Surgery Stent Placement Heart Bypass Hysterectomy Tubal Ligation Hip Replacement Knee Replacement Gall Bladder Endvenous Closure Injection Sclerotherapy Laser Sclerotherapy Vein Excision Vein Stripping PLEASE LIST ALL OTHER: Drug Allergies: No Allergies Latex Epinephrine Lidocaine Adhesive/Cloth Tape PLEASE LIST ALL OTHER: Current Medications: (please list name & dosage) Past Medical History: - Please Check all that apply High Blood Pressure Heart Disease Stroke Diabetes High Cholesterol List Other Medical History: Current Family History: Has anyone in your family been diagnosed with Varicose or Spider Veins? If so, who? Continued on reverse side Page 5
6 MEDICAL INFORMATION (continued) Have you had ANY of the following? Please Circle All That Apply SKIN Itching Hives Bruising Bleeding EYES Vision changes or loss Double Vision EARS Ringing Hearing Loss NOSE Nosebleeds Discharge MOUTH/THROAT Sore Throat Hoarseness RESPIRATORY Shortness of Breath Cough Wheezing PSYCHIATRIC Anxiety Depression Page 6 CARDIOVASCULAR Palpitations Chest Pain Cardiac murmers Irregular heartbeat High Blood Pressure High Cholesterol GASTROINTESTINAL Nausea Vomiting Diarrhea Constipation Blood in Stool Heartburn Jaundice GENITOURINARY Frequent urination Painful urination Bloody Urine Urgency/Frequency LYMPHATIC Swollen Glands Night Sweats Bleed easily Bruise easily NEUROLOGICAL Tingling/numbness Seizures Headaches Dizziness Falls Tremors Memory Loss MUSCULOSKELETAL Bone Pain Joint Pain Back Pain Swelling Calf Cramps ALLERGY/IMMUNE Aids/HIV Hepatitis B or C ENDOCRINE Cold intolerance Heat intolerance Weight gain/loss Diabetes Hot flashes
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