LTCS. Question 13 at end of 1/ADL section: "What are physical conditions that cause these limitations?"

Size: px
Start display at page:

Download "LTCS. Question 13 at end of 1/ADL section: "What are physical conditions that cause these limitations?""

Transcription

1 LTCS Question 13 at end of 1/ADL section: "What are physical conditions that cause these limitations?" Code Changes ( If no change indicated, disease is coded same as ) Title Abrasions 152 Abscess of lung 075 Accidents 152 Acne 110 Acute depression 053 Acute enteritas 073 Acute myocardial infarction Addison's disease 033 Adrenal deficiency 033 Afraid I had cancer 026 Afraid of ailing 053 "Age" Alcoholism 053 Allergy, respiratory 075 Allergy, skin 110 "Almost blind" 065 Alopecia 110 A.L.S. (Amyotrophic lateral sclerosis) 062 Alzheimer's Disease Amnesia 053 Amputation 122 Amyotonia 122 Amyotrophic lateral sclerosis 062 Anemia 040 Anemia, aplastic 040 Anemia, iron deficiency 040 Anemia, other deficiency 040 Anemia, pernacious 040 Anemia, severe 040 Anemia, sickle cell 040 Aneurism aortic Aneurism in brain Page 1

2 Angina, angina pectoris 091 Anxiety 053 Aplastic anemia 040 Appendicitis 084 Arm, chronic stiffness or deformity of 122 Arm, immobile 122 Arm, non-functional 122 Arteries (bypass, vascular, blocked, problems) 094 Arthritis Arthritis, rheumatoid Arthrogryposis 122 Artificial hip Artificial knee Asbestosis 075 Asthyma 075 Atelectasis 075 Athlete's foot 010 Arteriosclerosis (Hardening of Arteries) Ataxia of extremities 062 Back, chronic stiffness or deformity of Back, other trouble with Back pain Back trouble "Bad blood" 010 Bad blood circulation Bedridden by own choice 143 Bed sores 110 Bell's palsy 062 Benign tumor 027 Benign tumors, other kinds of 027 Biopsy 026 Birth defects 130 Black lung 075 Bladder, cancer 024 Bladder cord inplant 101 Bladder, diseases of the 101 Bladder infection 101 Bladder, loss of control of Bladder problem 101 Bladder, tumors of the 024 Page 2

3 Bleeding ulcer 081 Blind - serious trouble seeing 065 Blindness and Visual Impairment 065 Blindness or impaired vision not otherwise specified 065 Blood 040 Blood and blood forming organs, other diseases of 040 Blood clot in leg 040 Blood coagulation problem 040 Blood disease 040 Blood disorder 040 Blood, grease in 040 Blood in brain 094 Blood, low count 040 Blood poisoning 010 Blood problem 040 Blood stream, infection in 010 Blood sugar, high Blood sugar, low Blood, sugar in Blood, uric acid in 033 Boils 110 Bone ailments due to car accident 122 Bone cancer 023 Bone chips 122 Bone, connective tissue and skin, cancer of 023 Bone disease 122 Bone, other diseases of 122 Bone, Spurs 122 Bone, tumors of (not benign) 023 Both knees have pins 122 Bowel disease 084 Brain, cancer of 026 Brain, aneurism in Brain, blood in 094 Brain cells, drying up of Brain damage Brain deterioration Brain disturbance 062 Brain, hemorrhage Brain never developed 130 Brain operation 062 Page 3

4 Brain, organic syndrome Brain tumor 026 Breast cancer 028 Breast, diseases of the (Cysts, surgery, 102 exclude mastectomy) Broken hip (current injury) Broken hip (past injury) Bronchiolitis 074 Bronchitis 074 Brucellosis 010 Bruises 152 Bursitis 122 Callosities 110 Carbuncles 110 Cancer, location not specified 029 Cancer of the bladder 024 Cancer of the bone 023 Cancer of the brain 026 Cancer of the breast 028 Cancer of the intestine 021 Cancer of the kidney 024 Cancer of the liver 021 Cancer of the lung 022 Cancer of the mouth 020 Cancer of the pancreas 021 Cancer of the prostrate 024 Cancer of the skin 023 Cancer of the throat 020 Cancer, stomach 021 Cardiovascular disease Cartilage, rupture of 122 Cataracts 064 Celiac disease (vitamin D lack of 033 absorption includes rickets) Central nervous system disorder 062 Cerebral hemorrhage Cerebral sclerosis Cerebral seizures 062 Cervical spinal disease 122 Chemicals in eye 152 Page 4

5 Chickenpox 010 Choking 152 Cholesterol 033 Cholesterol, high 033 Chrohn's disease 084 Chronic bronchitis 074 Chronic intestinal problems 084 Chronic brain syndrome Chronic mucus colitis 083 Chronic skin ulcer 110 Chronic stiffness in fingers 122 Chronic stiffness or deformity of back or spine 122 Chronic stiffness or deformity of foot, leg, arm, or hand 122 Chronic stomach ailment 084 Circulation, poor 094 Circulatory problems 094 Circulatory system, other congenital anomalies of 130 Circulatory system, other diseases of 095 Cirrhosis of the liver 084 Cleft palate, cleft lip and hairlip 130 Club-foot 130 Coagulation defects (blood disorder problem) 040 Cold 075 Cold in eye 065 Cold sore 010 Colitis 083 Colitis, ulcerative 083 Collapsed lung 075 Colon 084 Colon, spasm of 084 Colon, spastic 084 Colon trouble 084 Colostomy Common cold 075 Complete paralysis Congenital anomalies of eye, ear, face, and neck 130 Congenital anomalies of genital organs 130 Congenital anomalies of heart 130 Congenital anomalies of musculoskeletal system 130 Congenital anomalies of skin, hair, and nails 130 Congenital anomalies of urinary system 130 Page 5

6 Congenital deaf mutism 130 Congenital joint disease 122 Congestive heart failure 094 Conjunctivitis 065 Connective tissue, cancer of 023 Connective tissue, diffuse diseases of 122 Convulsions 142 Cornea, scratched 065 Corns and Callosities 110 Coronary 091 Cross eyed 055 Croup 010 Crumbled bones in fingers 122 Cryptorchidism 102 Cystic Fibrosis 033 Cystitis (bladder inflammation) 101 Cystocele 102 Dandruff 152 DOT intoxication 066 Deaf mute (include congenital) 066 Deafness of Impaired Hearing 066 Deafness of serious trouble hearing 066 Deformity of knees 122 Degenerative hip Degenerative joint disease Dehydration 142 Dementia (other than senile) 053 Dementia, senile Depression 053 Depression, acute 053 Deterioration of disc 122 Diabetes Diabetes insipidus Diabetes mellitus Diabetes, sugar Diabetic retinopathy 065 Diarrhea 084 Did not want to get out of bed 143 Diffuse diseases of connective tissue 122 Digestive organs and peritoneum, cancers of 021 Page 6

7 Digestive problems 084 Digestive system, other congenital anomalies of 130 Digestive system, ulcers of the 081 Digestive track, inflammation of 084 Disc, deterioration of Disc, disease degeneration 122 Disc, displaced Disc, ruptured Diseases of the Ear 067 Diseases of the esophagus 084 Diseases of the kidney and bladder 101 Diseases of the oral cavity, salivary glands and jaws 084 Disorder in hip 122 Displaced disc 122 Diverticulitis 084 Dizziness 062 Dog bite 152 Down's syndrome affects multiple systems 130 Down's syndrome 130 Drug overdose 152 Drug addiction 053 Drying up of brain cells Duodeum ulcer 081 Dwarfism 033 Dyslexia 053 Ear, congenital anomalies of 130 Ear, disease of the 067 Ear drum, punctured 067 Ear infection 067 Ear, other diseases of 067 Ear, wax in 067 Eczema 110 Embolism 091 Emotional disturbance 053 Emotional problem 053 Emphysema 071 Endocrine, other diseases 033 Enteritis 073 Enlarged bowel 084 Epilepsy 062 Page 7

8 Erb's palsy 130 Esophagus closure 082 Esophagus, diseases of the 084 Esophageal hernia 082 Eye, chemical in 152 Eye, cold in 065 Eye, congenital anomalies of 130 Eye, foreign body in 065 Eye, hemorrhage of 065 Eye muscles, weak 065 Eye trouble 065 Face, congenital anomalies of 130 Fare of ailing 053 Fear of cancer 026 Female genital organs, other diseases of 102 Female trouble 102 Fever of unknownorigin 142 Fever, undulant 010 Fibroids - "afraid I had cancer but I did not" 027 Fingers, chronic stiffness in 122 Fingers, webbed 130 Flu 073 Flu, stomach 073 Foot, chronic stiffness or deformity of 122 Foot drop 122 Foreign body in eye 065 Forgetfulness Fractures Fungus 010 Gaiter 033 Gallbladder, chronic 084 Gallbladder operation 084 Gallbladder trouble 084 Gallstone 084 Gastritis 084 Gastro-intestinal problem 084 General poor circulation 094 Genitourinary system, cancer of 024 Genitourinary system, other diseases of 102 Page 8

9 Genital organs, congenital anomalies of 130 German measles 010 Gland, swollen 010 Glaucoma 063 Goiter 033 Gout 033 Grease in blood 040 Grippe 073 Growth 026 Guillian-Barre syndrome 062 Gums, infections in 010 Gunshot wounds 152 Hair, congenital anomalies of 130 Hardening of arteries Hand, chronic stiffness or deformity of 122 Hay fever 075 Headaches 062 Headaches, migraine 062 Headaches, severe 062 Hearing, loss of 066 Hearing problem 066 Hearing trouble 066 Heart attack Heart, congenital anomalies of 130 Heart failure, congestive Heart problem not otherwise specified Heart stroke 142 Hemophilia (internal hemorrhage; hemophiliac, 040 a bledder) Hemorrhage of eye 065 Hemorrhoids 095 Hemotoporetic tissue, cancer of 025 Hepatitis 084 Hernia 082 Hernia, esophageal 082 Hernia of abdominal cavity 082 Hernia, ruptured 082 Herpes zoster 010 Herpes (simplex) 010 Hiatus hernia 082 Page 9

10 High blood pressure High blood sugar (hyperglycemia) High cholesterol 033 Hip, artificial Hip, broken (current injury) Hip, broken (past injury) Hip, injury of hip (current) Hip, disorder in hip Hip missing Hip, operated on Hip out of joint (dislocated) Hip problems Hip, prosthesis in Hip replacement Hip socket, problem with Hip, stiffness in Hip with steel insert (pin) Histoplasmosis 010 Hives 110 Hodgkin's Disease 025 Hydrocele 102 Hydrocephalus 130 Hyperactivity 053 Hyperglycemia, high blood sugar Hyperglycemia, low blood sugar Hypertension Hyperthyroidism 033 Hysterectomy 102 Ileitis 084 Immobile arm 122 Impetigo 110 Incipient ulcer 081 Incontinent, bladder Incontinent, bowel Infection in blood stream 010 Infection in gums 010 Infectious bronchitis 074 Infectious hepatitis 010 Infectious mononucleosis 010 Inflammation of digestive track 084 Page 10

11 Inflammatory diseases of the ear 067 Influenza 073 Ingrown toenail 110 Injury of hip (current) 152 Inner ear trouble 067 Insect bite 152 Intestine, cancer of 021 Intestine, tumors of (not benign) 021 Intestinal disease 084 Intestinal problems 084 Intrathorac organ, cancer of 022 Iron deficiency anemias 040 Ischemic Heart Disease Itching 110 Jacksonian seizures 062 Jaws, diseases of the 084 Joints, other diseases of 122 Kidney ailment 101 Kidney, cancer of 024 Kidney condition 101 Kidney deformed 101 Kidney, dialysis Kidney, diseases of the 101 Kidney failure Kidney infection 101 Kidney, one 101 Kidney, other diseases (include surgery) 101 Kidney, polycystic condition 130 Kidney removed 101 Kidney stones 101 Kidney transplant Kidney trouble 101 Kidney, tumors of the (not benign) 024 Keratosis 110 Knee, artificial Knee cap broken (current) 151 Knee cap missing 122 Knee cartilage 122 Knee crumbling 122 Page 11

12 Knee disability 122 Knee drainage 122 Knee injury (current) 152 Knee joints 122 Knee lame 122 Knee problems 122 Knee, water on 122 Knees are weak 122 Knees, pins in Labrynthitis (inner ear dizziness) 067 Laryngitis 075 Learning disability 053 Leg, blood clot in 040 Leg, chronic stiffness or deformity of 122 Leg, one shorter than other 130 Leukemia 025 Limbs, other congenital anomalies of 130 Linked nerve 062 Lip, cancer of 020 Liver ailment 084 Liver, cancer of 021 Liver, cirrhosis of the 084 Liver diseased 084 Liver infection 084 Liver problems 084 Liver, tumors of (not benign) 021 Lock jaw 010 Loss of hearing 066 Loss of memory (due to amnesia) 053 Loss of memory (not due to amnesia) Loss of sleep 062 Low blood sugar (hyperglycemia) Low count in blood 040 Low sugar in blood Lumbago 122 Lump 026 Lung, abscess of 075 Lung, cancer of 022 Lung, collapsed 075 Lung removed 075 Page 12

13 Lung, tumors of (not benign) 022 Lupus (include lupus cannibus and lupus erythemathosis) Lymphatic tissue, cancer of 025 Lymphadenopathy 010 Lymphoma 025 Migraine headaches 062 Malaria 010 Male genital organs, other diseases of 102 Malnutrition Manic depressive 053 Mastectomy 028 Mastoid process, other diseases of 067 Measles 010 Memory, loss of (due to amnesia) 053 Memory, loss of (not due to amnesia) (includes forgetfulness) Menier's syndrome 067 Meningitis Menopausal symptoms 102 Mental disability 053 Mental disorders, other 053 Mental illness 053 Mental problems 053 Mental retardation 052 Mentally disturbed 053 Mentally handicapped 053 Mentally incompetent 053 Mentally sick 053 Metabolic, other diseases 033 Migraine headaches 062 Missing arms, hands, or fingers Missing legs or feet Mitral insufficiency Moles 027 Mongoloid 130 Mon-nucleosis 014 Mouth or throat cancer 020 Mouth, tumors of (not benign) 020 Mouth, ulcers in 010 Page 13

14 Multiple sclerosis Mumps 010 Muscle condition Muscle deterioration Muscle spasm in throat 084 Muscle spasms Muscle weak in legs Muscles do not move in legs Muscles, trouble with Muscular disease Muscular dystrophy Musculoskeletal system, congenital anomalies of 130 Myosthemia gravis Myelitis transverse 062 Nails, congenital anomalies of 130 Narcolepsy 062 Nasal congestion 075 Nearly drowned 152 Neck, congenital anomalies of 130 Neck injuries 152 Neck stiffness and pain 122 Neck trouble 122 Nephritis (kidney inflammation) 101 Nephrosis 102 Neoplasms Not Otherwise Specified 029 "Nerves" 053 Nerve damage 062 Nerve deterioration 062 Nerve, pinched 122 Nerve spasms 062 Nerve trouble due to sciatic 062 "Nerves," bad 053 "Nerves," hand shakes badly due to 053 "Nerves," problem with (due to emotional condition) 053 "Nerves," problem (due to physical condition) 062 Nervous breakdown 053 Nervous condition not otherwise specified 053 Nervous condition (problem) 053 Nervous disorder 053 Nervous (nervousness) 053 Page 14

15 Nervous stomach 084 Nervous system, other congenital anomalies of 130 Nervous system, other diseases of 062 Neuritis (nerves) 062 Neurological 062 Neurosis 053 Non-fatal auto accident 152 Non-functional arm 122 Nosebleed 152 Nose, cartilage in 122 Nutritional, other diseases 033 Obesity 032 "Old" "Old age" Onychitis 102 One kidney 101 Operation in stomach 084 Oral cavity, cancer of 020 Oral cavity, diseases of the 084 Osgood-Schlatter disease 122 Ostelparalysis 122 Osteo - arthritis Ostecmyelitis 122 Osteoporosis Other acute cerebral vascular diseases Other arterial disease 095 Other bacterial pneumonia Other cerebral vascular disease 094 Other congenital anomalies of digestive system 130 Other congenital anomalies of circulatory system 130 Other congenital anomalies of limbs 130 Other congenital anomalies of nervous system 130 Other congenital anomalies of respiratory system 130 Other congenital anomalies of upper alimentary track 130 Other congenital anomalies (specified and unspecified) 130 Other deficiency anemias 004 Other deformities of muscularskeletal syst and connective tissue122 Other diseases of blood and blood forming organs 004 Other diseases of bone and joints 122 Other diseases of circulatory system 095 Page 15

16 Other diseases of ear and mastoid process 067 Other diseases of female genital organs 102 Other diseases of genitourinary system 102 Other diseases of male genital organs 102 Other diseases of Nervous system 062 Other disease of urinary track (include surgery) 102 Other disease of the nervous system and sense organs 062 Other diseases of the respiratory system 075 Other diseases of the skin 110 Other diseases of the upper respiratory track 075 Other endocrine, nutritional and metabolic diseases 033 Other kidney diseases (include surgery) 101 Other kinds of benign tumors 027 Other local infections of skin 110 Other mental disorders 053 Other phobias 053 Other respiratory allergies 075 Other trouble with back or spine Other unspecified sites, cancer of 026 Oxygen, lack of -- at birth 130 Pacemaker 094 Paget's disease 122 Pain, not specified 141 Palpitations 094 Pancreas, cancer of 021 Pancreas disease 084 Pancreas, tumors of (not benign) 021 Pancreatitis 084 Paralysis Paranoia 053 Paraplegic 062 Parkinson's Disease Part of stomach removed 084 Partial paralysis 062 Pectus 130 Pelvic infection 102 Penicilliosis, serve 010 Peptic ulcer 081 Pernecious anemia 040 Pernitoneum, cancer of 021 Page 16

17 Petit mal 062 Pharynx, cancer of 020 Phlebitis 095 Phobias, other (any phobias) 053 Psychotic organic brain syndrome Phychosis 053 Pinched nerve 122 Pink eye 065 Plastic stomach 084 Pleural effusion 075 Pneumonia Poison Ivy 110 Polio 010 Poliomyolitis Polyps 027 Poor circulation 094 Poor circulation, loss of balance due poor 094 circulation in legs Problem with hip socket 122 Problems with ribs 122 Prostate (prostatistis) (disease, include surgery) 102 Prostate, cancer 024 Prostate, tumors 024 Prosthesis in hip Pseudoxanthoma elasticum 110 Psoriasis and Similar Disorders 110 Psychiatric help 053 Psychological problems 053 Pulled muscle 152 Punctured ear drum 067 Puspocket in nerve going to brain 062 Rashes, unspecified 110 Raynaud's disease 095 Rectal problems 084 Renal disease Renal sclerosis (kidney disease) 101 Respiratory allergies, other 075 Respiratory and intrathorac organ, cancer of 022 Respiratory problems 075 Respiratory system, other congenital anomalies of 130 Page 17

18 Respiratory system, other diseases of the 075 Rheumatic fever Rheumatism Rheumatoid arthritis Rhinitis 075 Rib removed 122 Ribs broken 151 Ribs, problem with 122 Rickets 033 Rubella roseola 010 Rupture of cartilage 122 Ruptured disc Ruptured hernia 082 Ruptured stomach 084 Salivary glands, diseases of the 084 Sarcoidosis 010 Scarlet fever 010 Schizophrenia 053 Sciatica 062 Sclerosis, amyotrophic lateral 062 Sclerosis, cerebral Sclerosis, tuberous 130 Scoliosis 122 Scratched cornea 065 "Senile" Senile dementia Senile psychotic conditions Senility without psychosis Sense organs, other diseases of the 062 Severe anemia 040 Severe penicilliosis 010 Shaking (due to nerves) 062 Shaking (in arms and legs) 122 Shingles 010 Shock treatment 053 Shortness of breath 075 Shortwinded 075 Shoulder, torn ligament in 122 Sickle cell anemia 040 Sinus 075 Page 18

19 Sinus, chronic 075 Sinus drainage 075 Sinus headaches 075 Sinus, high fever 075 Sinus in nose and eyes 075 Sinusitis 075 Skin allergy 110 Skin cancer 023 Skin, congenital anomalies of 130 Skin, local infection 110 Skin, other diseases of the 110 Skin, tumors of (not benign) 023 Skin ulcer 110 Sleep, loss of 053 Sleep, problem with 053 Slight hearing problem 066 Smell, loss of sense of 062 Sore throat 075 Soreness and pain in pelvic area 102 Spasm of colon 084 Spasm (due to nerves) 062 Spasm (in arms and legs) 122 Spastic colon 084 Speech, loss of 053 Spina-bifida 130 Spine, chronic stiffness or deformity of Spine, curve of Spine, deterioration of Spine, injury 152 Spine, lower part missing Spine, other trouble with Spine, trouble with Spleen (removed, diseased) 040 Splinter 152 Sprains 152 Spurs 122 Stab wounds 152 Staggery 122 Stammering 130 Staph infection 010 Stepped on nail 152 Page 19

20 Stiffness in hip 122 Stomach ache 084 Stomach cancer 021 Stomach, chronic stomach ailment 084 Stomach, flu 073 Stomach, nervous 084 Stomach operation 084 Stomach, part of removed 084 Stomach, plastic 084 Stomach problems 084 Stomach, ruptured 084 Stomach spasms 084 Stomach ulcer 081 Strep throat 010 Stress 053 Stroke Stye 065 Sugar diabetes Sugar in blood Sunburn 110 Sun poisoning 110 Swallowing foreign object 152 Swelling, hand, and feet 095 Swollen gland 010 Swollen pancreas 084 Syphilis 010 Tachycardia 094 Taste, loss of 062 Tendinitis 122 Tendon pinched 122 Testicle, diseases of 102 Testicle, undescended 102 Tetanus 010 Throat, cancer of 020 Throat, undescended 084 Throat, problem 075 Throat, strep 010 Throat, tumors of (not benign) 020 Thrombophlebitis 095 Thrombosis 091 Page 20

21 Thrush 010 Thyroid Thyroid condition (problem) Thyroid, low Thyroid, neuropathy Thyroid, underactive Tic douloureax 062 Toenail, ingrown 110 Toes, webbed 130 Tongue-tied 130 Tonsillitis 075 Tooth extracted 152 Trench mouth 010 Trichinosis 010 Trouble with muscles Tuberculosis (incl all reltd tubercellar effts) 010 (act, inact, arrest) Tuberous sclerosis 130 Tularemia 010 Tumor, bladder (not benign) 024 Tumor, bone (not benign) 023 Tumor, intestine (not benign) 021 Tumor, kidney (not benign) 024 Tumor, liver (not benign) 021 Tumor, lung (not benign) 022 Tumor, mouth (not benign) 020 Tumor, pancreas (not benign) 021 Tumor, prostate (not benign) 024 Tumor, skin (not benign) 023 Tumor, throat (not benign) 020 Tumor, unspecified (not benign) 026 Ulcerative, colitis 083 Ulcer, bleeding 081 Ulcer, skin 110 Ulcers in mouth 001 Ulcers of the Digestive System 081 Undescended testicle 102 Undulant fever 010 Unspecified viral infection (virus) 010 Page 21

22 Upper ailmentary track, other congenital anomalies of 130 Upper respiratory track, other diseases of the 075 Uremia 102 Urethral stricture 102 Uric acid in blood 033 Urinary system, congenital anomalies of 130 Urinary track, other diseases of 102 Uterus problems 102 Unspecified rashes 110 Van Recklinghausen's disease 130 Varicocele 095 Varicose veins 095 Vascular disease 094 Vascular problem 094 Vein problems 095 Veins, varicose 095 Vertebrae, plastic 122 Viral infection 010 Viral pneumonia 072 Virus 010 Vision poor 065 Vocal cord difficulties 075 Warts 010 Water on knee 122 Wax in ear 067 Weak eye muscles 065 Webbed fingers and toes 130 Whooping cough 010 Worms 010 Wrist, broken 151 Wrist, growth in 122 Wrist, spurs on 122 Page 22

Limited Pay Policy (L-222B) - Underwriting Guidelines

Limited Pay Policy (L-222B) - Underwriting Guidelines Limited Pay Policy (L-222B) - Underwriting Guidelines 1 Addiction/Abuser Drug - Past or Present Presently Recovered - AA for last 2 years 2 Aids 3 Alcoholic Presently Recovered - AA for last 2 years 4

More information

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 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.

More information

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

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

More information

How To Fill Out A Health Declaration

How To Fill Out A Health Declaration The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance

More information

Height FT IN Weight Married? Y / N Employed? Y / N

Height FT IN Weight Married? Y / N Employed? Y / N Name Patient # (PLEASE PRINT) Signature Date Height FT IN Weight Married? Y / N Employed? Y / N Previous Illnesses: Check all that apply AIDS, HIV, STD Epilepsy Pacemaker Alcoholism Eye/vision problems

More information

Pulmonary Associates of Richmond

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

More information

PATIENT INFORMATION INSURANCE INFORMATION

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

More information

Patient Information. Name: Social Security Number: Birth date: Email: Address: Phone #: House: Cell: Work: Primary Care Physician: Address:

Patient Information. Name: Social Security Number: Birth date: Email: Address: Phone #: House: Cell: Work: Primary Care Physician: Address: Patient Information Name: Social Security Number: Birth date: Age: Email: Address: Phone #: House: Cell: Work: Primary Care Physician: Phone #: Date Last Visit: Address: Emergency Contact: Emergency Phone

More information

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

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.)

More information

PATIENT REGISTRATION

PATIENT REGISTRATION PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital

More information

Surgery Health Survey

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:

More information

Description Code Recommendation Description Code. All natural death 001-799 IPH All natural death A00-R99

Description Code Recommendation Description Code. All natural death 001-799 IPH All natural death A00-R99 Natural death Description Code Recommendation Description Code All natural death 001-799 IPH All natural death A00-R99 Infectious and parasitic diseases 001-139 CDC, EUROSTAT, CBS & VG Infectious and parasitic

More information

New Patient Intake Form

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

More information

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

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

More information

Name Last First Middle. (Complete Mailing) Address ** Street Apt# City State Zip. Work Phone # ( ) ** Emergency Contact Relationship Phone# ( )

Name Last First Middle. (Complete Mailing) Address ** Street Apt# City State Zip. Work Phone # ( ) ** Emergency Contact Relationship Phone# ( ) Today s Date NEW PATIENT REGISTRATION Name Last First Middle (Complete Mailing) Address ** Street Apt# City State Zip Social Security # Home Phone # ( ) ** Date of Birth Work Phone # ( ) ** Cell Phone

More information

Workman s Compensation

Workman s Compensation Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

More information

Patient Intake Form. Patient Information. How did you find out about our office?

Patient Intake Form. Patient Information. How did you find out about our office? Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our

More information

WELCOME PATIENT CONDITION

WELCOME PATIENT CONDITION NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer

More information

PATIENT HISTORY FORM

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

More information

Sports Health Insurance. application for sports players

Sports Health Insurance. application for sports players Sports Health Insurance application for sports players Here to Help We hope you will find this application form easy and straightforward to complete but if you require any assistance the General & Medical

More information

Patient Medical History

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

More information

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot. : 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:

More information

MEDICAL HISTORY AND SCREENING FORM

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

More information

Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission

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

More information

Interventional Spine Pain Consultants, P.A. Initial Consultation Information

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?

More information

Around the navel: appendicitis; constipation; gas. Lower right side: acute appendicitis; colitis; Crohn s disease; uterine fibroids or polyps.

Around the navel: appendicitis; constipation; gas. Lower right side: acute appendicitis; colitis; Crohn s disease; uterine fibroids or polyps. Troubleshooting for Disorders Some symptoms are indicative of a variety of illnesses. The following table lists some of the more common disorders that are associated with particular symptoms. It is not

More information

Medical Specialties Guide

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,

More information

Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by

Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance

More information

Patient & Medical Professional US Online Panel

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

More information

CitizenSecure Economy Application and Rates

CitizenSecure Economy Application and Rates CitizenSecure Economy Application and Rates Important Instructions for All Applicants 1. Review your answers to each question on this Application for accuracy. Unanswered questions or incomplete information

More information

AUBURN DERMATOLOGY PATIENT DEMOGRAPHIC (Please print legibly)

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:

More information

Life & PHI Application Form

Life & PHI Application Form Life & PHI Application Form A. Applicant 1) Mr Mrs Miss Other: 2) Family Name: 3) First Name: 4) Date of Birth: 5) Nationality: 6) Place of Birth: 7) Location of Assignment: 7) Occupation (please give

More information

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 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

More information

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 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

More information

Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD

Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Responsible Party Telephone Number Date Name of Child Date of Birth Time of Birth Sex Resident County Placement County

More information

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 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

More information

(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:

(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

More information

Mid-State Neurosurgery, P.C Back & Neck Pain Center

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

More information

WORKERS COMPENSATION INFORMATION

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:

More information

Patient Information Form Pain Management Center at Phoebe

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

More information

Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:

Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender: Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social

More information

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

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:

More information

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone

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

More information

LA OWCA Second Injury Board Knowledge Questionnaire WARNING

LA OWCA Second Injury Board Knowledge Questionnaire WARNING 1001 North 23 rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) 225-342-7866 800-201-2493 (F) 225-219-5968 Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation

More information

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

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

More information

LA OWCA Second Injury Board Knowledge Questionnaire WARNING

LA OWCA Second Injury Board Knowledge Questionnaire WARNING 1001 North 23 rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) 225-342-7866 800-201-2493 (F) 225-219-5968 Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation

More information

Name: Last First MI. Mailing Address: City State Zip. Email Address: Phone# (H) (W) (M)

Name: Last First MI. Mailing Address: City State Zip. Email Address: Phone# (H) (W) (M) Chart #: Patient Information Name: Last First MI Mailing Address: City State Zip Email Address: Phone# (H) (W) (M) Date of Birth: Sex: Male Female SS#: Marital Status: Single Married Divorced Widowed Separated

More information

One (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)

One (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI) Eligibility Criteria for Health Home Services: Chronic Conditions New York State s Health Home eligibility criteria is as follows: Medicaid eligible/active Medicaid; and Two (2) or more chronic conditions;

More information

Critical Illness with Term Assurance

Critical Illness with Term Assurance AIG Life Critical Illness with Term Assurance Our comprehensive Critical Illness with Term Assurance delivers more value and quality to the customer and their family than ever before. It is designed to

More information

What Each Vitamin & Mineral Does In Your Body. Vitamin A

What Each Vitamin & Mineral Does In Your Body. Vitamin A What Each Vitamin & Mineral Does In Your Body Vitamin A Prevents skin disorders, such as acne, wrinkling and age spots. Enhances the immune system protects against colds, flu, and infections to kidney,

More information

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527

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

More information

NEW PATIENT INFORMATION FORM

NEW PATIENT INFORMATION FORM Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.

More information

Gastroenterology Specialists of Delaware, LLC

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

More information

Phoenix Remembrance Life

Phoenix Remembrance Life Phoenix Remembrance Life W e You Asked New Printer- Friendly Design! D e l i v e r e d Field Underwriting Guide For agent use only. Not for distribution to the public as sales literature. Phoenix Remembrance

More information

PLEASE PRINT LEGIBLY

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

More information

Integrated Medical Services (IMS) New Patient Registration Sheet

Integrated Medical Services (IMS) New Patient Registration Sheet Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:

More information

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

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:

More information

Medical conditions that preclude entry

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

More information

Medical Surgical Nursing (Elsevier)

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

More information

List of Qualifying Conditions

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)

More information

Long Term Use of Antacid Medications Can Cause an Increased Risk for Osteoporosis and Much More

Long Term Use of Antacid Medications Can Cause an Increased Risk for Osteoporosis and Much More Long Term Use of Antacid Medications Can Cause an Increased Risk for Osteoporosis and Much More By: Jeremie Pederson D.C., C.S.C.S. Many people are concerned about the FDA news release dated May 25, 2010

More information

Private medical insurance Corporate Healthcare employee application form Full medical underwriting

Private medical insurance Corporate Healthcare employee application form Full medical underwriting Private medical insurance Corporate Healthcare employee application form Full medical underwriting To be used for plans taken out with PruHealth after March 2011. To apply for PruHealth membership complete

More information

San Luis Dermatology & Laser Clinic, Inc.

San Luis Dermatology & Laser Clinic, Inc. San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: LOCATION Health History Intake Form The federal government has defined a complete electronic medical record (EMR) or electronic health

More information

17. Undiagnosed lumps and bumps and unexplained areas of pain. 2. Varicose veins (do not treat anything below the vein site).

17. Undiagnosed lumps and bumps and unexplained areas of pain. 2. Varicose veins (do not treat anything below the vein site). 15. Acute rheumatism. 16. Asthma. 17. Undiagnosed lumps and bumps and unexplained areas of pain. 18. Whiplash. 19. Slipped Disc. LOCAL CONTRA-INDICATIONS 1. Skin diseases (non contagious). 2. Varicose

More information

Company private medical insurance

Company private medical insurance For office use only SR. Company private medical insurance Group member application form - Full Medical Underwriting Important: please read this section and then complete the application in BLOCK CAPITALS

More information

2012 LONG TERM DISABILITY CLAIMS REVIEW

2012 LONG TERM DISABILITY CLAIMS REVIEW 2012 LONG TERM DISABILITY CLAIMS REVIEW The 2012 Council for Disability Awareness Long Term Disability Claims Review Since 2005, the Council for Disability Awareness (CDA) has conducted a proprietary annual

More information

Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor

Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor Dr. Anne Desneiges Inner Waves Centre for Well~Being Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor Name: Address: Postal code: street city Telephone: home: ( ) work:

More information

Registered Marks of the Blue Cross and Blue Shield Association. ' Registered Mark of USAble Life Insurance Company M-5437 5/04

Registered Marks of the Blue Cross and Blue Shield Association. ' Registered Mark of USAble Life Insurance Company M-5437 5/04 Application for Individual Health, Dental & Life Insurance Instructions Please print your responses and use a ballpoint pen. Press hard for good copies. Be sure that all sections of the application are

More information

We have made the following changes to the Critical Illness events covered under our group critical illness policy.

We have made the following changes to the Critical Illness events covered under our group critical illness policy. We have made the following changes to the Critical Illness events covered under our group critical illness policy. March 2015 Because everyone needs a back-up plan 7 New critical illness events added to

More information

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all

More information

Asteron Life Business Insurance

Asteron Life Business Insurance Asteron Life Business Insurance What lump sum covers are available with Asteron Life Business Insurance? Life Cover Life Cover pays a lump sum of money if you pass away or become terminally ill. Total

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

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

More information

MEDICAL HISTORY INFORMATION

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:

More information

Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #

Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License # Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License

More information

LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME HEALTH QUESTIONNAIRE

LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME HEALTH QUESTIONNAIRE LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME HEALTH QUESTIONNAIRE SECTION 1 PERSONAL DETAILS Mr. Mrs. Ms. Date of birth: First Name: Surname: Address: Contact Numbers: Home Work Mobile Email SECTION

More information

Workers Compensation Employee Personnel Forms

Workers Compensation Employee Personnel Forms Workers Compensation Employee Personnel Forms JOB DESCRIPTION / ESSENTIAL FUNCTIONS JOB TITLE/DESCRIPTION Once a conditional job offer is made, please be aware all persons may be required to furnish health

More information

Translated version of Genomsnit.. (1).doc

Translated version of Genomsnit.. (1).doc Translated version of Genomsnit.. (1).doc The average general medicine specialist s work in Sweden A general medicine specialist s work in Sweden differs from most other EU countries in that it includes

More information

Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form

Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Insurance

More information

Application Form. New application Change my current plan/deductible. Add spouse/partner/dependents Reinstatement

Application Form. New application Change my current plan/deductible. Add spouse/partner/dependents Reinstatement Application Form Important: Please make sure all the information required on this health insurance application has been provided. Best Doctors Insurance Limited reserves the right to contact the if a question

More information

Plano Heart Center, P.A.

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:

More information

Medical Matters Action Checklists

Medical Matters Action Checklists Medical Matters Action Checklists The following Action Checklists are included in Chapter 5: Medical History Personal Medication Record Health Care Power of Attorney Medical Orders (Do Not Resuscitate/POLST)

More information

Range of Injury Scale Values

Range of Injury Scale Values Range of Injury Scale Values Civil Liability Regulations 2014 SCHEDULE 4 Range of Injury Scale Values (summary) Item Injury ISV Range Part 1-Central Nervous System and Head Injuries 1 Quadriplegia 75 100

More information

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration

More information

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? 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

More information

ORANGE COUNTY EYE INSTITUTE

ORANGE COUNTY EYE INSTITUTE ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do

More information

WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.

WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you. HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.

More information

LIFE BOLD SIMPLE DIFFERENT. A personal approach to life cover LIFE

LIFE BOLD SIMPLE DIFFERENT. A personal approach to life cover LIFE LIFE SIMPLE BOLD DIFFERENT A personal approach to life cover LIFE ALEXANDER FORBES LIFE Protecting your wealth to secure your financial well-being Flexible, to change as often as life does. You can change

More information

GUIDE. Prepare for Your Phone Interview and Medical Exam.

GUIDE. Prepare for Your Phone Interview and Medical Exam. GUIDE Prepare for Your Phone Interview and Medical Exam. WHAT YOU NEED TO HAVE, KNOW, AND DO. All information gathered during the interview and exam will be shared only with those who need it in order

More information

Medical History Form

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

More information

Known Donor Questionnaire

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

More information

PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )

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

More information

PATIENT DEMOGRAPHICS:

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?

More information

GrapeGate v1.0 Info@GrapeGate.com

GrapeGate v1.0 Info@GrapeGate.com As you begin the process of alkalizing and granting the body more energy for cleansing itself (and also for regeneration), many symptoms and seemingly adverse reactions can occur throughout this process

More information

Asteron Life Personal Insurance

Asteron Life Personal Insurance Asteron Life Personal Insurance What lump sum covers are available with Asteron Life Personal Insurance? Life Cover Life Cover insurance pays a lump sum of money if you pass away or become terminally ill.

More information

NOTICE OF INJURY/ILLNESS REPORT

NOTICE OF INJURY/ILLNESS REPORT Office of the President University of Massachusetts NOTICE OF INJURY/ILLNESS REPORT This form is intended for internal use for all Human Resources Division/Workers Compensation Unit user agencies and must

More information

CONTENTS SECTION 1 FUNDAMENTALS 1 SECTION 2 DRUGS 75 SECTION 3 DIGESTIVE DISORDERS 109. A Guide for Readers Understanding Medical Terms

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

More information

Dental Admission Form

Dental Admission Form Dental Admission Form PERSONAL HISTORY All of the information which you provide on this form will be held in the strictest confidence. Although some questions may seem unimportant at the time, they may

More information

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 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

More information