PATIENT NAME: Birth date:_________________
ADDRESS:
Social Security #
Street,
Apt. No.
City: State:
Zip: ___________
Home
Phone: ( ) County:
Sex Race Religion _______
MAIDEN NAME: (Single patients or male patients give mothers
maiden name)
Single
____ Married ____ Widowed ____ Separated ____ Divorced ____
PATIENT EMPLOYER
NAME: ADDRESS:___________________________________
Employer Phone: ( )
Street, Appt..
No. City, State, Zip
Occupation: Employment
Status: Full Time Part Time
Retired Unemployed Disabled
(PLEASE CIRCLE )
PERSON TO NOTIFY
NAME: ADDRESS:
Phone:
( ) Relationship
NEXT OF KIN (If same as person to
notify leave blank)
NAME: ADDRESS:
Phone:
( ) Relationship
GUARANTOR (Who is responsible
for bill: self or (who is brining pt in today if minor) NOT INSURANCE
NAME: ADDRESS:
Phone:
( ) S.S. Number
GUARANTOR EMPLOYER
NAME: ADDRESS:
EMPLOYMENT STATUS: please circle one: FULL TIME PART TIME UNEMPLOYED DISABLED
IF PATIENT IS A MINOR WE NEED BOTH PARENTS EMPLOYMENT INFORMATION. THIS SECTION IS FOR THE
PARENT THAT IS NOT LISTED IN
THE GUARANTOR INFORMATION ABOVE.
NAME:
SS# DATE OF BIRTH
ADDRESS RELATIONSHIP TO PATIENT
EMPLOYER NAME AND ADDRESS PHONE
EMPLOYMENT STATUS: OCCUPATION
INSURANCE POLICY NUMBER COVERAGE
NO. SUBSCRIBER REL OFFICE COPAY
1.
2.
Primary
Care Physician Reason for Visit
READ
AND SIGN
I
hereby authorize payment directly to my physicians’ office, of any Insurance
coverage for treatment rendered, and authorize them to release any information
necessary to process these insurance claims.
I
understand that I am fully responsible for all social services and charges,
including any balance due after payment of insurance and that insurance
coverage does not necessarily pay all charges.
I
also understand that doctor and office fees are due and payable when services
rendered.
I,
the undersigned, authorize treatment by the physician of this office.
SIGNATURE:
(If Minor, Parent or Guardian
Signature)
DATE:
Type
of Accident related to this visit: WHEN
TREATMENT IS RELATED TO ACCIDENT MEDICARE, WORKMAN’S COMPENSATION OR OTHER
LIABILITY
PATIENT
EMPLOYED: Yes No
RETIRED: Yes
No
SPOUSE
EMPLOYED: Yes No
COVERED
BY GROUP INSURANCE: Yes No
Liability
A/A Comp Sports Injury ______
1. WORKMAN’S COMPENSATION Date of
Accident:
Brief description of accident:
Employer:
Phone #: ( )
Address:
Phone #: ( )
Comp Carrier Phone #: ( )
Verified
Yes No
Date
Verified: By:
Contact Person (Name & Title)
Comments:
2. OTHER LIABILITY AND/OR SPORTS INJURY: Date of
Accident:
Reason:
Responsible Party’s Name:
Address:
Phone #: ( ) Relationship:
Primary Insurance
Policy Number
Secondary Insurance
Policy Number
3. AUTO ACCIDENT
Auto Insurance Coverage: Yes No
Responsible Party’s Name:
Address:
Name
of Insurer:
Agents Name/Address:
Attorney’s Name: Address:
Phone #: ( )
PATIENT HEALTH INFORMATION
PLEASE ANSWER QUESTIONS TO THE BEST OF YOUR ABILITY
NAME _______________________________________
AGE ________ SEX _________ MARITAL STATUS __________
OCCUPATION _______________
CURRENT HEALTH STATUS
ALLERGIES _______________________________________________
MEDICINES DOSAGE HOW OFTEN DATE
BEGAN LAST TAKEN
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
IMMUNIZATIONS: Were you ever immunized
as a child for any of the following diseases?
Circle Yes or No
Diptheria Yes
No Polio Yes No
Tetanus Yes
No
Pertussis Yes
No Rubella Yes
No
Whooping Cough Yes
No Hepatitis B Yes
No
Date of last: Tetanus Shot _________ Pneumonia Shot __________
Flu Shot _____________ TB Test ____________
If possible please provide a
copy of your immunizations record.
PAST HEALTH HISTORY
Please list all
hospitalizations, surgeries and injuries.
Include dates, hospital, physicians.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Family Health History
To the best of your knowledge, do any of your immediate
family members have
any of the following?
If yes who?
High Blood
Pressure __________________________
Heart Disease
________________________________
Stroke ______________________________________
Diabetes
____________________________________
Cancer
_____________________________________
Lung Disease
________________________________
Ulcers
______________________________________
Arthritis
_____________________________________
Headache
____________________________________
Anemia (low
iron) _____________________________
Bleeding
Disorder _____________________________
Thyroid
Disorder ______________________________
Liver Disease
_________________________________
Epilepsy/Seizures
______________________________
Asthma
______________________________________
Kidney Disease
________________________________
Alcohol/Drug
Addiction _________________________
Anxiety
______________________________________
Depression
____________________________________
H.I.V.
________________________________________
Patient’s Signature _______________________________________
Date ___________________________
Have you ever had any of the following? Circle Y or N
High Blood Pressure Y
N Bleeding
Disorder Y N
Heart Disease Y N Thyroid
Disorder Y N
Stroke Y
N Liver Disease Y N
Diabetes Y N Epilepsy/Seizures Y N
Cancer Y
N Asthma Y N
Lung Disease Y N Kidney
Disease Y N
Ulcers Y N Alcohol/Drug
Abuse Y N
Arthritis Y N Anxiety Y N
Headaches Y N Depression Y N
Anemia/Low
Iron Y N H.I.V. Y N
Please list other illnesses
which you think would be helpful in your care.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Life Habits
1. Do you or have you ever used tobacco, in any
form? Y N
Age started ____ Age Quit ____ Type and Amount
________________
2. How much coffee, tea and/or soda do you drink
in a day? __________
3. How much alcohol do you drink? Daily _________ Weekly _________
Less than 3 months ______________ Never
______________
4. How many hours of sleep do you get within a
24 hour period? _________
5. Date of last PAP __________
6. Date of last PSA screening _________
7. What type of exercises do you practice? Running _________ Aerobics _______
Walking ___________ None __________ Other ___________
8. What activities do you do for fun?
___________________________________
__________________________________________________________________
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT FORM
I
have received or I have been provided the opportunity to receive a copy of the
Notice of Privacy Practices that explains when, where, and why my confidential
information may be used or shared. I
acknowledge that
Patient
Name ______________________________
Chart Number __________________
Signature
________________________________________
Patient (or Designated
Representative)
Relationship
to Patient __________________________
Date
____________________
Employee
______________________________
In
order to help control the cost of billing, we request payment be made for all office
services at the conclusion of your visit unless other arrangements have been
made prior to services being rendered.
I
authorize any holder of medical or other information about me to release to the
Social Security Administration and Health Care Financing Administration or its
intermediaries or carrier or any other commercial insurance company, any
information needed for this or related
Regulations
pertaining to
Signature
____________________________________
Date
_________________________