Oklahoma State University Medical Center Collinsville Family Practice Dr. Fred Ingram, Dr. Patrick Allen and Deb Bell, PA (918)
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1 Oklahoma State University Medical Center Collinsville Family Practice Dr. Fred Ingram, Dr. Patrick Allen and Deb Bell, PA (918) Welcome to Oklahoma State Medical Center- Collinsville Primary Care. We are honored that you have chosen us as your health care provider. Our goal is to provide the highest quality care for all of our patients in a timely and respectful manner. We will do our best to provide you with same-day office visits and accept walk-ins for first available slots for all sick visits. You will need to bring your insurance card and a photo ID with you for each appointment. Please let our staff know if you have had any information changes since your last appointment. You will be asked to fill out new registration forms annually so we may update your information as it is a requirement. All co-pays and past due balances are expected at time of service, unless a prior agreement has been made. If you are a self pay patient and do NOT have insurance we will offer you a 40% discount if you pay in full the same day as your visit. If you are unable to pay the full amount payment arrangements can be made but we will not be able to offer the discount. We ask that you allow plenty of time to get to the office for your appointment. Your appointment will be cancelled if you are greater than 15 minutes late. We will strive to stay on time. From time to time, a patient emergency arises and we may be running late for your visit. You will have the option to reschedule or stay to be seen and we will keep you informed of how long of a delay you may experience. Please bring all of your prescription and over-the-counter medications (vitamins, natural remedies, etc) with you at each visit. Our office policy for a missed appointment is: You must give a 24 hour notice of cancellation for your appointment. If you have 3 or more missed appointments you will receive a warning letter to remind you that keeping your appointments are necessary to give you the best care possible. In order to achieve the best outcome for your medical care it is pertinent that you maintain your regularly scheduled follow up appointments. If you have three (3) no-show appointments it will result in dismissal from the practice. We understand that appointments sometime need to be changed, so we ask that you call in advance if you cannot keep your scheduled appointment. (918) Providing the highest quality of professional care to our patients is very important to us. Therefore, the following guidelines for dispensing medications in our office have been established: 1. Our physicians here at Collinsville Primary Care do not offer chronic pain management and will not dispense chronic pain medication (for example, chronic daily narcotics like Norco or
2 Percocet). We will provide you with a referral to a pain management center if you need this specialized form of care after evaluation by our physicians. 2. If you are on a medication that requires refills for a chronic disease (for example, high blood pressure or diabetes), you will be given ample refills for 30, 60 or 90 days at a time upon our physicians discretion during your office visit. a. We ask that you allow enough time for us to make an appointment for management of your chronic disease so you re not without your medication. 3. For the safety and well-being of our patients, a. Requests for new medications (including antibiotics) and medication refills will not be taken over the phone or over the Internet during office hours without an appointment and evaluation by the physician. b. No new medications (including antibiotics) will be called in over the phone after office hours by the on-call physician. c. We understand that unexpected situations arise, thus a small refill of a chronic medication will be granted for one or two days after office hours on an as-needed basis determined by the on-call physician. This allows patients to be seen and evaluated by the physician during office hours for all their medication refills. If you need to reach the physician after hours, you can reach our answering service at Our office hours for patient care are 8am 5pm Monday Friday. If you have a concern that you feel management needs to be made aware of please notify our nursing manager, Angela Kihega, RN at Our physicians are affiliated with Oklahoma State University Medical Center. They will be directing their patients to use OSUMC s services. Using our own network allows us to get your results and documentation in a timelier manner. Welcome to our practice and thank you for choosing Collinsville Primary Care and Oklahoma State University Medical Center for your medical needs. We look forward to serving your needs. Sincerely, Fred Ingram, D.O Patrick Allen, D.O Deb Bell, PA
3 NEW PATIENT MEDICAL HISTORY FORM Oklahoma State University Medical Center Collinsville Primary Care- Dr. Ingram, Dr. Allen & Deb Bell, PA 1205 W. Main St. Collinsville, OK (918) Date / / Name: Date of Birth: / / Marital Status: Married / Single / Divorced / Widowed (please circle) PLEASE COMPLETE ALL PAGES- IF YOU ARE UNSURE OF EXACT DATES ESTIMATES WILL BE FINE. Reason for your visit today: MEDICATIONS: Please list ALL medications- prescription and over the counter medications (example: natural remedies, vitamins, tylenol, etc.) Medication Ex: Tylenol Dosage Ex: 500mg Frequency Ex: 1 3x day Started month/yr Ex 12/2013 Prescribed by: Ex: Dr Smith Medication or Food Allergy (ex: cipro) Type of reaction (ex: rash)
4 Check Mark each immunization that you have had: Hepatitis A Date: / / Varicella Date: / / (chicken pox) Hepatitis B Tetanus Shot Date: 1.) / /, 2.) / /, 3.) / / Date: / / (Was pertussis included TDAP)? Yes / No (circle one) Influenza (flu) Date: / / Rubella Date: / / Pneumonia Date: / / Zostavax Date: / / (Shingles Vaccine) Measles Date: / / Flu Vaccine Date: / / HPV (3 shots) Date 1.) / /, 2.) / / /, 3.) / /. Please write the approximate dates of the most recent tests you have completed / / Bone Density Screening (osteoporosis) / / Colonoscopy/EGD / / Cardiac Stress Test / / EKG / / Pap Smear / / Diabetic A1C Lab Test / / Cholesterol/Lipid labs / / Prostate exam / / Chest X-Ray / / Ultrasound (if yes what Kind?) / / / / MRI (If yes what body area- brain, back, legs, arms, other-please circle) Mammogram/Breast- if abnormal please give details: Other testing you may have had done that is not listed here:
5 SURGICAL HISTORY: Surgery Type: Physician/Surgeon Date : month/year Location/Hospital FAMILY HISTORY Relation Heart Disease Diabetes Lung Disease Cancer/ Type Stroke High Cholesterol High Blood Pressure Mental Illness Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Siblings Brother/Sister Siblings Brother/Sister Siblings Brother/Sister Siblings Brother/Sister Please List any other pertinent family history here: Age(now or at death
6 SOCIAL HISTORY: 1. Do you smoke? ( ) No, I have never smoked. ( ) Yes, I smoke packs of cigarettes a day for yrs. ( ) No, I quit smoking yrs. ago. I smoked packs a day for yrs. ( ) Yes, I smoke cigars or a pipe, a day for yrs. ( ) Yes, I use snuff times a day or times a week or only on Occasion. 2. Do you drink alcoholic beverages? ( ) Beer cans per day / week / month / year (circle one) ( ) Wine glasses per day/ week / month / year (circle one) ( ) Other: How Much?. 3. How much caffeine do you drink on a daily basis: (coffee, tea, colas)?. 4. Have you ever used illicit drugs (marijuana, meth, heroin, cocaine, LSD, etc)? Yes / No Currently using / Used in the past (circle one) Last used Have you ever used illicit drugs intravenously? Yes / No If yes please list illicit drugs that are/ or were used:. Are you sexually active? Yes / No Are your partners male / female / or both? (Please circle) Do you use contraception? None Condoms Pill Vasectomy IUD Diaphragm Tubal Ligation (please circle) Do you practice safe sex? Never / Sometimes / Always (please circle) For Woman Only: Number of pregnancies: Number of live births: Number of abortions/miscarriages: Date of your last period? / / What is your occupation:. Please check if the following pertain to safety behaviors you follow: ( ) Wear Seatbelt ( ) Wear helmet while riding bike or motorcycle ( ) Smoke detector in home ( ) Fire extinguisher in home ( ) Guns in the home ( ) Guns are kept locked up at all times
7 Do you have advanced directives? (Living Will, Durable Power of Attorney for medical decisions) Yes / No (please circle one) If No, would you like information regarding advanced directives? Yes No Do you have a signed DNR (Do Not Resuscitate)? Yes No (please circle one) Please list any other physicians or health care providers you see (specialist, therapists, counselors, chiropractors, eye doctors, etc) Provider: Provider: Provider: Provider: Reason: Reason: Reason: Reason: Hospitalizations: Month/Year Hospital Name/ Location (city, state) Reason for hospitalization Review of Symptoms/Health History: Please check any current problems you are having listed below: General Fevers/Chills/Sweats Unexplained weight loss/gain Unusual fatigue Excessive thirst or urination Hot flashes Musculo-Skeletal Muscle/ Joint Pain Back Pain Cardiovascular Chest pain/discomfort Irregular heart beat swelling of feet or hands High blood pressure Heart Murmur Pacemaker in place- Year Defibrillator Year History of blood clots History of heart attack Stents?
8 Please check any of the problems you are experiencing: (continued) Ears/Nose/Throat/ Sore throat/ hoarseness Nasal Congestion Hay fever/ allergies Hearing loss right/ left/ both Ringing in ears Nose bleeds Ear Pain Left / Right Respiratory Cough productive/ Non-productive Shortness of breath Asthma Wheezing Genitourinary Frequent urination Painful urination Slow urine stream Bladder leakage (incontinent) Unusual vaginal bleeding or discharge Penile discharge Painful sexual intercourse Psychiatric Anxiety/stress Problems with sleep (insomnia) Depression Mood swings Irritability Claustrophobic Blood/Lymphatic Bruises easily Bleeds excessively Cancers? Skin Changes in moles Rashes Itching Breast (Woman Only) Breast Lump left / right/ both (circle) Nipple Discharge left /right /both Gastrointestinal Constipation Diarrhea Abdominal Pain Nausea/ or vomiting Gallbladder issues Heartburn Coughing up blood Blood in stools Hemorrhoids Men Only Prostate problems Impotence Last prostate exam / / Neurological Headaches Dizziness/ light headedness Leg pain/numbness General weakness Memory Loss Loss of balance Seizures History of stroke, if so / / Have you had a recent fall? / / Eyes Change in vision Blurred vision Cataracts Glaucoma Last eye exam / / Mouth Dentures? If so what age? Jaw pain/ popping Dental problems Frequent mouth sores
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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
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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