Emergency Medicine EOR Exam Topic List
|
|
|
- Ethelbert Wilkinson
- 8 years ago
- Views:
Transcription
1 CARDIOLOGY PULMONARY Chest pain Palpitations Dyspnea on exertion Orthopnea Edema Syncope Conduction disorders (atrial fibrillation/flutter, supraventricular tachycardia, bundle branch block, ventricular tachycardia/fibrillation, premature beats) Hypertensive emergencies Hypotension (cardiogenic shock, orthostatic hypotension) Heart failure Coronary heart disease (acute MI (non-st/st segment elevation), angina pectoris, unstable angina, Prinzmetal/variant angina) Vascular disease (aortic aneurysm/dissection, arterial occlusion/thrombosis, phlebitis) Valvular disease (aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation) Acute/subacute bacterial endocarditis Cardiac tamponade Pericardial effusion MUSCULOSKELETAL Pain Swelling/deformity Ecchymosis/erythema Fractures/dislocations (shoulder, forearm/wrist/hand, hip, knee, ankle/foot) Soft tissue injuries Back strain/sprain Low back pain Cauda equine Herniated disk Osteomyelitis Septic arthritis Shortness of breath Wheezing Hemoptysis Pleuritic chest pain Acute bronchitis Acute bronchiolitis Acute epiglottitis Croup Influenza Pertussis Pneumonia (bacterial, viral, fungal, HIV-related) Respiratory syncytial virus Asthma Pleural effusion Pneumothorax Pulmonary embolism Acute respiratory distress syndrome Foreign body aspiration
2 GASTROINTESTINAL EENT Abdominal pain Anorexia Nausea/vomiting Heartburn Jaundice Hematemesis Melena; bleeding per rectum Change in bowel habits/diarrhea/constipation Esophagitis Mallory-Weiss tear Peptic ulcer disease Acute cholecystitis Cholangitis Acute hepatitis Acute pancreatitis Acute appendicitis Diverticular disease Ischemic bowel disease Inflammatory bowel disease/toxic megacolon Obstruction (small bowel, large bowel, volvulus) Anal fissure/fistula/abscess Hemorrhoids (thrombosed) Hernia (incarcerated/strangulated) Infectious diarrhea HEMATOLOGY Easy bruising Fatigue Aplastic anemia Hemolytic anemia Sickle cell anemia/crisis Clotting factor disorders Hypercoagulable states Thrombocytopenia Acute leukemia Vision loss Nasal congestion Sore throat Ear pain Vertigo Blepharitis Conjunctivitis Blow-out fracture Corneal abrasion/ulcer Dacryoadenitis Foreign body (eye, ear, nose) Glaucoma (acute angle closure) Hyphema Macular degeneration (wet) Optic neuritis Orbital cellulitis Papilledema Retinal detachment Retinal vein occlusion Otitis externa Acute otitis media Trauma/hematoma external ear Barotrauma/TM perforation Labyrinthitis Mastoiditis Acute sinusitis Epistaxis Acute pharyngitis (viral, bacterial) Peritonsillar abscess Dental abscess Acute laryngitis Epiglottis
3 NEUROLOGY DERMATOLOGY Vertigo Seizure (symptom) Numbness/paresthesias Weakness/paralysis Loss of consciousness/change in mental status Loss of memory Loss of coordination/ataxia Headache (migraine, cluster, tension) Meningitis Encephalitis Transient ischemic attack Stroke Subarachnoid hemorrhage/cerebral aneurysm Intracerebral hemorrhage Altered level of consciousness/coma Head trauma/concussion/contusion Epidural/subdural hematoma Seizure disorders Status epilepticus Syncope Guillain-Barré syndrome Itching Rash Discharge Dermatitis (eczema, contact) Drug eruptions Stevens-Johnson syndrome Toxic epidermal necrolysis Bullous pemphigoid Lice Scabies Spider bites Viral exanthems Herpes zoster Cellulitis Erysipelas Impetigo Burns Urticaria Pilonidal disease Pressure sores Spinal cord injury ENDOCRINOLOGY Palpitations Heat/cold intolerance Tremors Hyperparathyroidism Hyperthyroidism Thyroiditis Adrenal insufficiency Diabetes insipidus Diabetic ketoacidosis Non-Ketotic hyperglycemia
4 GENITOURINARY PSYCHIATRY Dysuria Hematuria Suprapubic/flank pain Incontinence Nephrolithiasis Testicular torsion Cystitis Epididymitis Orchitis Prostatitis Pyelonephritis Urethitis Acute renal failure Glomerulonephritis Fluid and electrolyte disorders Acid/base disorders Thought disorder Changes in mood Hallucinations Suicidal/homicidal ideations Depression Generalized anxiety disorder Panic disorder Post-traumatic stress disorder Substance abuse disorders Domestic violence Suicide WOMEN S HEALTH Vaginal discharge Pelvic pain/dysmenorrhea Amenorrhea Dysfunctional uterine bleeding Endometriosis Ovarian cysts Vaginitis Pelvic inflammatory disease Mastitis/breast abscess Spontaneous abortion Abruption placenta Ectopic pregnancy Placenta previa Premature rupture of membranes Fetal distress
5
Patient Medical History
Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral
*Effective July 6, 2016*
*Effective July 6, 2016* 1. Cardiovascular Emergencies 20 A. Acute coronary syndrome B. Aneurysm/dissection C. Cardiopulmonary arrest D. Dysrhythmias E. Endocarditis F. Heart failure G. Hypertension H.
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
POLICY AND PROCEDURE MANUAL
Policy Title: Authorization for Observation vs. Inpatient Admission for Contracted Hospitals Primary Department: Affiliated Department(s): N/A Last Revision Date: 09/12/2014 Revision Dates: 12/16/2011;
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
Inpatient Rotations Goals and Objectives Third and Fourth Years
Inpatient Rotations Goals and Objectives Third and Fourth Years Faculty: Members of the LSU Department of Pediatrics Goal: To develop competency in caring for, and supervising care of, infants, children,
MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY Graduate Program - Family Nurse Practitioner Sequence
MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY Graduate Program - Family Nurse Practitioner Sequence Culminating Clinical Behaviors The following list, although not all-inclusive, is a compilation
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Health Plan, Inc. Policy & Procedure Subject: Emergency Room Service Claims Line of Business (check all that apply) Effective Date:
Health Plan, Inc. Claims Policy & Procedure Subject: Emergency Room Service Claims Line of Business (check all that apply) Effective Date: Commercial: FI ; SF Review Date: Medicaid Next Review Date: Medicare
Medical Surgical Nursing (Elsevier)
1 of 6 I. The Musculoskeletal System Medical Surgical Nursing (Elsevier) 1. Med/Surg: Musculoskeletal System: The Comprehensive Health History 2. Med/Surg: Musculoskeletal System: A Nursing Approach to
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
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
SOUTH PALM CARDIOVASCULAR ASSOCIATES, INC. CHARLES L. HARRING, M.D. NEW PATIENT INFORMATION FORM. Patient Name: Home Address:
NEW PATIENT INFORMATION FORM Today s Date: Referred by: Patient Name: (First) (Last) Date of Birth: Gender: M / F SSN: Home Address: Home Phone (Area Code & No.): ( ) - Cell Phone: ( ) - Secondary Address
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
Cardiovascular diseases. pathology
Cardiovascular diseases pathology Atherosclerosis Vascular diseases A disease that results in arterial wall thickens as a result of build- up of fatty materials such cholesterol, resulting in acute and
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015
PHC4 35 Diseases, Procedures, and Medical Conditions for which Laboratory Data is Required Effective 10/1/2015 Laboratory data is to be submitted for discharges in the following conditions: 1. Heart Attack
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission
Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission Non surgical Spinal Care for Severe Neck, Shoulder, Low Back & Leg Pain If you are reading this you have been fortunate
Patient & Medical Professional US Online Panel
Patient & Medical Professional US Online Panel Patient & Medical Professional US Online Panel Over 500K validated US online double opt-in panelists motivated to share their opinions in research! Since
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
Acute Care Nurse Practitioner Board Certification Test Content Outline effective date: March 1, 2010 Based on the 2008 NP Role Delineation Study
Test Content Outline effective date: March 1, 2010 Based on the 2008 NP Role Delineation Study There are 175 questions on this examination. Of these, 150 are scored questions and 25 are pretest questions
Alameda Alliance for Heath ICD-9 to ICD-10 TRANSLATION CODES E10.10
DIABETES ICD-9 CM ICD-9 CM Volume 1 - Diagnosis Description ICD-10 CM - Diagnosis Code ICD-10 CM - Diagnosis Description 250.00 Diabetes mellitus without mention of complication, type II or unspecified
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
CONTENTS SECTION 1 FUNDAMENTALS 1 SECTION 2 DRUGS 75 SECTION 3 DIGESTIVE DISORDERS 109. A Guide for Readers Understanding Medical Terms
CONTENTS A Guide for Readers xxxix Understanding Medical Terms xli SECTION 1 FUNDAMENTALS 1 1 The Human Body 2 2 Genetics 8 3 Making the Most of Health Care 17 4 Prevention 28 5 Exercise and Fitness 38
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
Patient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
Eger Eye Group, P.C.
Eger Eye Group, P.C. Last Name: Middle Initial: First Name: Birth Date: Street Address: City/State/Zip: Home Phone: ( ) Work Phone: ( ) Email: Occupation: Employer: Soc. Sec. #: Age: Sex: M F Race: Accompanied
The Acute Abdomen. Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital
The Acute Abdomen Dr. Ed Snyder Dr. Melanie Walker Huntington Memorial Hospital Causes of the Acute Abdomen Hemorrhage in the GI tract Blood vessel GU tract Perforation of the GI tract Ulcer Infection
List of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
*3451 BARIATRIC SERVICE HEALTH QUESTIONNAIRE
BARIATRIC SERVICE HEALTH QUESTIONNAIRE Name: Male Female Address: City: State: Zip: Home Phone: ( ) E-Mail: Mobile Phone: ( ) Primary Language: Religious Preference : Education Level: Date of Birth: Social
Medical Specialties Guide
Medical Specialties Guide Allergy And Immunology Specialists in this field treat disorders related to how the body reacts to foreign substances. They treat such things as seasonal allergies, eczema, asthma,
Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations.
INTRODUCTION Coronary Artery Disease leading cause of morbidity & mortality in industrialised nations. Although decrease in cardiovascular mortality still major cause of morbidity & burden of disease.
Medical conditions that preclude entry
Medical conditions that preclude entry If you have or have had any of the conditions listed below, it means that you do not meet the current medical standard required to enter RAF service: Eye disorders
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
NAME OF THE HOSPITAL: 1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3
1. Coronary Balloon Angioplasty: M7F1.1/ Angioplasty with Stent(PTCA with Stent): M7F1.3 1. Name of the Procedure: Coronary Balloon Angioplasty 2. Select the Indication from the drop down of various indications
Title: Nurse Practitioner Guidelines Original Date: 02/01/1996 Last Revision Date: 01/04/2012 Approved by: David Altman, MD Effective Date: 01/04/2012
Purpose: To delineate the guidelines for practice of nurse practitioners within the scope of services provided by the Alliance. Policy: The Alliance requires that all Alliance Nurse Practitioners shall
VIDEO LIBRARY PATIENT EDUCATION. Primary Care
Primary Care AC Arthritis ACL Injuries Acute Bronchitis Alcoholic Hepatitis All About Arthritis Allergic Rhinitis Am I a Candidate for LASIK? Amblyopia Anaphylaxis Anemia of Chronic Disease Angioedema
Physician Assistant Self Assessment
Physician Assistant Self Assessment Directions Please circle a value for each question to provide us and the interested facilities with an assessment of your clinical experience. These values confirm your
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
MS-DRG NEWS. Reporting Secondary Diagnoses that Impact MS-DRG Payment
MS- Effective 10/01/12 Inside this issue: Impact of Reporting Accuracy Impact More Than Payment 2 3 MCC s 4 Common CC s 5 Avoid Non- Specific Terminology 6 Reporting Secondary Diagnoses that Impact MS-DRG
The Lewin Group undertook the following steps to identify the guidelines relevant to the 11 targeted procedures:
Guidelines The following is a list of proposed medical specialty guidelines that have been found for the 11 targeted procedures to be included in the Medicare Imaging Demonstration. The list includes only
Clinical Presentation (Preclerkship; Year 1 & 2)
Clinical Presentation (Preclerkship; Year 1 & 2) Definition of a Clinical Presentation A clinical presentation must: Represent a common or important way in which a patient, group of patients, community
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Medical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient Name: Date: Address: City: State: Zip Code Best Phone Number: Marital Status Phone (H): (W) (Cell):
Stretcher Transportation Services
Stretcher Transportation Services Decision Guide for Choosing Appropriate Patient Transportation April 20, 2015 Version 1.0 Implementation Branch Health System Performance and Accountability Division Ministry
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
Patient Interview Form
Patient Interview Form www.austingastro.com Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
Cardiology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Cardiology
Cardiology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Cardiology Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) The diabetes mellitus codes are combination codes
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM. Reason for Consultation: Physicians involved in your care:
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date: Reason for Consultation: Physicians involved in your care: PAST MEDICAL HISTORY HEAD, EYES, EARS CARDIOVASCULAR
NCD for Lipids Testing
Applicable CPT Code(s): NCD for Lipids Testing 80061 Lipid panel 82465 Cholesterol, serum or whole blood, total 83700 Lipoprotein, blood; electrophoretic separation and quantitation 83701 Lipoprotein blood;
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Thank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring
PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient
PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner
Medical History Form
Compassionate Care for Women Medical History Form Date First Name Maiden/Middle Name Last Name Date of Birth How did you learn about Brandon Gynecology Associates, PA? Past OB/Gyn History Last menstrual
Alphabetical List of Sickness Reasons by Sickness Category available for selection on Health Roster Maps Manager
Description of Sickness Reported Abdominal pain Adrenal disorders Alcoholism Allergic (extrinsic) asthma Allergic rhinitis Alzheimer's disease Amniotic fluid disorders Anaemia Angina Animal bite Anthrax
(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:
Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to
Advanced Eye Care, SC Patient Registration Form
Advanced Eye Care, SC Patient Registration Form (Please print and complete all entries.) Patient Name (First-MI-Last) Date of Birth Age Circle Marital Status Single Married Parent/Guardian (if patient
Gastroenterology Specialists of Delaware, LLC
I, authorize, to discuss any aspects of my health including office visit arrangement, diagnosis and plan of care with Dr. George Benes/Dr. Michael J. Brooks and his staff. Patient Name: DOB: Print Full
Medicare Supplement Plans Underwriting and Administration Guide
Medicare Supplement Plans Underwriting and Administration Guide 024227 (09-2011) Table of Contents Introduction....1 Underwriting Concepts...1 Coverage....1 Eligibility Requirements...1 Eligibility Considerations...1
MEDICAL HISTORY INFORMATION
MEDICAL HISTORY INFORMATION Name: Birthdate: Age: Address: Home Telephone: Cell Telephone: Work Telephone: Social Security Number: Marital Status: Single Married Divorced Widowed Spouse s Name: Birthdate:
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
71 Spit Brook Road, Suite 407 Nashua, NH 03060
71 Spit Brook Road, Suite 407 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to serve you better.
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
Diagnosis Code Crosswalk : ICD-9-CM to ICD-10-CM Cardiac Rhythm and Heart Failure Diagnoses
Diagnosis Code Crosswalk : to 402.01 Hypertensive heart disease, malignant, with heart failure 402.11 Hypertensive heart disease, benign, with heart failure 402.91 Hypertensive heart disease, unspecified,
Preoperative Laboratory and Diagnostic Studies
Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Certified Clinical Documentation Specialist Examination Content Outline - 2016
Certified Clinical Documentation Specialist Examination Content Outline - 2016 1. Healthcare Regulations, Reimbursement, and Documentation Requirements Related to the Inpatient Prospective Payment System
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly)
AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly) Patient Legal Name: DOB: M/F Home Phone: Work Phone: Cell Phone: Mailing Address: City: State: Zip: Preferred Email: Married: Single: Widowed:
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
Mid-State Neurosurgery, P.C Back & Neck Pain Center
Mid-State Neurosurgery, P.C Back & Neck Pain Center Patient Name: Date of Birth: Heart HISTORY Attack OF PRESENT ILLNESS Stroke Seasonal Allergies Diabetes What is the reason for today s visit? When did
Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:
Eastside Medical Group: DATE: Name: Date of Birth: _Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here: SOCIAL HISTORY Marital Status: Single Married Partner Divorced Widow/Widower
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
NUR 111: INTRO TO HEALTH CONCEPTS
NUR 111: INTRO TO HEALTH CONCEPTS 1. Fluid & Electrolytes Basic fluid balance Basic electrolyte balance 2. Elimination Bladder incontinence & retention Bowel incontinence, constipation, impaction Urinary
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.
High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
Cutting Edge Eye Care
Cutting Edge Eye Care The Optos Daytona provides an unequaled 200 degree view of your retina in a single image. This view gives our doctors the opportunity to identify and follow peripheral retinal pathology
PATIENT INFORMATION (Please Print) Patient First Middle Initial Last. Email : ( Please avoid using Work Email Address)
PATIENT INFORMATION (Please Print) Date: Patient First Middle Initial Last Birthdate: / / Marital Status: Address: City: State: Zip Code: Primary Phone: ( ) Secondary Phone: ( ) By supplying your email
CIGNA GLOBAL HEALTH OPTIONS APPLICATION FORM HELLO
CIGNA GLOBAL HEALTH OPTIONS APPLICATION FORM HELLO We re glad you would like to join us. Please complete this application form and return it to us, either by electronic mail, fax or post. See our contact