PATIENT REGISTRATION

Transcription

1 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 Status: ( ) Single ( ) Married ( ) Other Patient s Sex: ( ) Male ( ) Female Drug Allergies: Patient s Employer (blank if patient s a minor) Reason for visit: Name of Referring Doctor, Address, &# Name of Primary Insurance: Name of Policy holder: Date of birth: Insurance ID# Group# Policy holder s SS#: Policy holder s address: Name of Secondary Insurance: Name of Policy holder: Date of birth: Insurance ID# Group# Policy holder s address: All services rendered are charged to the patient. The patient is responsible for payment regardless on insurance coverage. Full payment is expected at the time of each visit. In all instances when the patient is covered by a health insurance company with whom this office is a participating provider, we will verify eligibility and benefits directly with your insurance company. When necessary, we are happy to discuss this information with you in any effort to justify the amount you will be expected to pay. However, it is ultimately the responsibility of your insurance company to provide the education on the benefits available to you. All

2 copayments, coinsurance, and deductibles are due at the time services are rendered. I hereby authorize the provider of services to release medical information concerning my examination and/or treatment for insurance purposes and to receive direct payment for medical benefits payable to me for services rendered. I, the undersigned, have completed this registration form to the best of my knowledge. Also, I have read and fully understand the payment policy & authorization of payment outlined above. I understand that if I need letters or medical records for my personal use, I will get charged a fee according to the office policy. I understand that if I cancel my appointment with less than 24 hours in advance or no show to my appointment or the appointment of my dependents, I will get charged $50.00 Signature:

3 History and Intake Form Past Medical History: (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure HIV/AIDS High Cholesterol Thyroid Problems Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Other Past Surgical History: (please circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy (Nephrectomy) Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP (Prostate Removal) Spleen Removed

4 Testicles Removed (Right, Left, Bilateral) NONE Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Other Skin Disease History: (please circle all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Poison Ivy Other Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, which relative(s)? Medications: (Please enter all current medications)

5 Allergies: (Please enter all allergies) Social History: (Please circle all that apply) Cigarette Smoking: Currently Smokes Has smoked in the past Never smoked Former Smoker Alcohol Use: EtOH- None EtOH- less than 1 drink per day EtOH -1-2 drinks per day EtOH -3 or more drinks per day Other Family History (Only first degree relatives) Preferred Language: Race: Ethnic Group: Preferred pharmacy Name: Phone#:

6 City or Zip code: ALERTS: (please circle all that apply) Allergy to Adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heart beat with epinephrine Are you pregnant or currently trying to get pregnant? Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following) Symptom Yes No Fever or Chills Night Sweats Unintentional Weight Loss Nausea Vomiting Sore Throat

7 Rash Oral Sores Genital Sores Vision Problems Immunosuppression Hay Fever Chest Pain Shortness of Breath New or Changing Moles Swollen Glands Problems with Breathing Problems with Healing Problems with Scarring Dry Eyes Dry Lips Dry Skin Joint Aches Muscle Weakness Nosebleeds Bloody Stools Abdominal Pain Dizziness Problems with Night Vision Blurry Vision Headaches Neck Stiffness

8 Depression Suicidal Ideation Anxiety Bloody Urine