Wednesday, 10 March, 2010

Let us give you the treatment that you deserve.

New Patient

HIPAA Notice of Privacy Policy

New Patient Form -
NEW PATIENT FORM -
We encourage you to fill out a new patient form before coming to the office. This will save you time and make the office administration process easier. You may either a) fill out the information online and then print the page or b) print this page and complete the form by hand. If you are filling out the information online, please remember to print the form after you are done as the information is not saved for your protection.
PATIENT INFORMATION
     
Today’s Date (mm/dd/yyyy):
 
Personal Information
First Name: Last Name: Middle Initial:
Permanent Address:
City: State/Province: Zip Code:
Country (if outside US): Phone 1: Phone 2:
Local Address (if different from Permanent):
City: State/Province: Zip Code:
Social Security Number: Sex: Male Female  
Date Of Birth:  Marital Status: Married Single Divorced Widowed
Employer: Employer Phone:  
E-mail:  
Pharmacy: Pharmacy Phone:  
 
     
Insurance Information
(PLEASE PROVIDE ALL CURRENT INSURANCE CARDS AT REGISTRATION)
Primary Insurance Company:
Is this: Medicare Medicare HMO Medicaid PPO HMO Other:
Group Number: ID Number:  
Secondary Insurance Company:
Is this: Medicare Medicare HMO Medicaid PPO HMO Other:
Group Number: ID Number:  
 
     
Referral Information
(PLEASE PROVIDE REFERRAL AT REGISTRATION)
     
Referring Physician:
Referring Physician Phone #:
Primary Care Physician (if different):
PCP Phone #:
     

PATIENT MEDICAL HISTORY
           
Allergies
   
   
   
   
   

General Medical: Have you ever experienced or been diagnosed with any of the following?
Condition
Yes
No
 Specify (if applicable)
Chest Pain
Shortness of Breath
Hypertension (High Blood Pressure)
Hyperlipidemia (High Cholesterol)
Myocardial Infarction (Heart Attack)
Congestive Heart Failure (Heart Failure)
Abnormal Heart Beat
Lightheadedness/Passing Out
Enlarged Heart
Heart Murmur
Rheumatic Fever
Stroke
Blood Clots
Peripheral Vascular Disease
Swelling or Aching in Legs
Other Vascular
Excessive Fatigue
Diabetes
Gastrointestinal Problems
Orthopedic Problems
Asthma
Emphysema
Other Respiratory Problems
Headaches
OB/GYN Problems
Thyroid
Urinary Problems/Genitourinary
Hematological
Immunological
Psychological/Psychiatric
Neurological Problems
Other
Other
Other

About You
Have you ever smoked? If so, how many packs /day for years.
  Do you currently smoke?
Do you exercise? How often?
Do you drink alcohol? How much? /month
Do you drink coffee? How much? /month
     

Current Medications
Medication
Dosage (Mgs.)
Times Per Day
     
Past Surgery & Hospitalizations
Surgery Reason Date (mm/dd/yyyy)

Family History
Relative
Age (or age of death)?
History of Heart Disease
History of High Blood Pressure?
History of Heart Attack?
History of Diabetes?
History of Stroke?
If Deceased, Cause of Death
Mother
Father
Brother
Brother
Sister
Sister
Grandmother-Mother's Side
Grandfather-Mother's Side
Grandmother-Father's Side
Grandfather-Father's Side
Other (Specify)
Other (Specify)
               

EMERGENCY CONTACT INFORMATION
     
Spouses/Significant Other Contact Information
Spouse Name:
Spouse Address (if different):
City: State/Province: Zip Code:
Country (if outside US): Home Phone:
Cell Phone: Pager:
Spouse Occupation:
Spouse Employer: Spouse Work Phone:
Other Relative Emergency Contact
Name of Nearest Relative:
Relationship to Patient:
Home Phone: Work Phone:
Cell Phone: Pager:
IN CASE OF EMERGENCY, I HEREBY AUTHORIZE YOU TO CONTACT THE FOLLOWING EMERGENCY CONTACT(S):
(Please check one or both)  
Spouse/Significant Other Nearest Relative  
     
PLEASE BE AWARE THAT IN CASE OF EMERGENCY, I HAVE COMPLETED THE FOLLOWING DOCUMENTS THAT I WILL PROVIDE TO THIS PHYSICIANS OFFICE WITHIN 10 DAYS OF SIGNATURE BELOW. I AM AWARE THAT MY REQUESTS CANNOT BE FOLLOWED UNLESS APPROPRIATELY SIGNED LEGAL DOCUMENTS ARE MAINTAINED IN THIS CHART OR PROVIDED AT THE TIME OF EMERGENCY.
     
Living Will DNR-Do Not Resuscitate  
     
You may sign this when you come to the appointment
______________________
Signature of Patient
______________________
Witness Signature
______________________
Patient Name
______________________
Witness Name
______________
Date