Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
*Please complete all fields, if it does not apply please list N/A TODAYS DATE_________________ PATIENTS INFORMATIONName ________________________________________Date of Birth __________SSN# __________________ Home Phone #_________________________________ Cell Phone #__________________________________ Address_______________________________________City__________________State________Zip________ Male [ ] Female [ ] Race __________________Ethnicity __________________Language________________ Emergency Contact________________________Relationship________________Phone___________________ Insurance Subscribers Name and Date of Birth____________________________________________________ Primary Insurance Type and I.D. Number________________________________________________________ Secondary Insurance Type and I.D. Number______________________________________________________ Referral Required? [ ] yes [ ] no Email address ________________________________________________ Pharmacy Name_____________________ City _______________________Telephone #__________________ Reason for Your Visit Today __________________________________________________________________ Height __________Weight ___________BP _______________Pulse______________Temp._______________ PHYSICIAN INFORMATION-(First and Last Name) Primary Care Physician:_____________________________ Practice Name:____________________________ Referring Physician: ________________________________Specialty:________________________________ MEDICATIONS WITH DOSAGES- ALLERGIES- [ ] None [ ] See Attached [ ] No known drug allergies [ ] See Attached Latex [ ] Yes [ ] No REVIEW OF SYSTEMS- Are you currently experiencing any of the following: Weight gain [ ]yes [ ]no Weight lost [ ]yes [ ]no Chest pain [ ]yes [ ]no Palpitations [ ]yes [ ]no Gait Disturbance (trouble walking) [ ]yes [ ]no Headaches [ ]yes [ ]no Joint Pain [ ]yes [ ]no Muscle Weakness [ ]yes [ ]no Hearing Loss [ Visual changes [ ]yes [ ]no Moles [ ]yes [ ]no Rash [ ]yes [ ]no Anxiety [ ]yes [ ]no Depression [ ]yes [ ]no Easy Bruising [ ]yes [ ]no Lymphadenopathy [ ]yes [ ]no Cough or Shortness of Breath [ ]yes [ ]no Heat Or Cold Intolerance [ ]yes [ ]no ]yes [ ] no Patients Name ______________________________________Date of Birth _______________ HEALTH HISTORYHigh Blood Pressure [ ]yes [ ]no Lung Disease [ ]yes [ ]no Diabetes [ ]yes [ ]no Type I or Type II Anxiety/Depression [ ]yes [ ] no Cardiac Disease [ ]yes [ ]no Other: -Do you smoke? [ ] Never [ ] Previous Smoker- Age Quit _______ [ ] Current Smoker: How Frequently? [ ] Daily [ ] Weekly [ ] Monthly. -Do you drink alcohol? [ ] No [ ] Yes- What type?___________Drinks per week? ____Last Drink _________ -Last Colonoscopy- Date ____________________Results__________________________________________ -Have you had an Influenza Vaccine? [ ] no [ ] yes- Date: ________ -Have you had a Pneumonia Vaccine? [ ] no [ ] yes- Date: ________ -Have you fallen in the past 2 years? [ ] no [ ] yes- How many times? ________ SURGICAL HISTORYProcedure: [ ] None [ ] See Attached Date: FAMILY HISTORY- (Breast/Ovarian cancer or other health condition) Relationship: Condition: Age Diagnosed: Deceased: [ ]yes [ ]no [ ]yes [ ]no [ ]yes [ ]no [ ]yes [ ]no [ ]yes [ ]no BREAST HEALTH HISTORYLast Mammogram- Date ___________Facility: ___________________ Results__________________________ Last Ultrasound- Date _____________Facility: ___________________ Results__________________________ Breast Lump [ ]yes [ ] no [ ] Right [ ] Left Breast Pain [ ] yes [ ] no [ ] Right [ ] Left Nipple Discharge [ ] yes [ ] no [ ] Right [ ] Left Age of First Menstrual? Last Menstrual? Any possibility you could be pregnant? [ ]yes [ ]no Number of Pregnancies? Live Births? Your Age at First Live Birth: Number of Miscarriages and/or abortions: Do you perform self-breast exams? [ ] yes [ ] no Describe your findings: Hormone Use: Birth Control: [ ] yes [ ] no Type: Fertility Hormones: [ ]yes [ ] no Type: Estrogen Replacement Therapy: [ ]yes [ ]no Type: How many years: Which child? Additional Notes: Nursing History: How long? Patients Name ____________________________________Date of Birth _________________ I hereby authorize Doylestown Health Breast Surgery to release my PHI (protected health information) to: ______Myself only ______My spouse/significant other Name of person ______My Children Name of person Name of person Name of person ______Other Relationship to Patient Names of person/organization I give my permission to LEAVE MESSAGES ON VOICE MAIL regarding: test results, answers to questions, appointment information, etc. Doylestown Health Breast Surgery 1. Acknowledgement of Receipt: I acknowledge I have been provided the Notice of Privacy Practices on this day. 2. Assignment of Benefits: I hereby assign to Doylestown Health Breast Surgery all benefits payable to me for my care and/or treatment. 3. Financial Agreement: I agree to be responsible for charges not covered by insurance. In consideration of the service to be rendered, I acknowledge the obligation to pay VIA Affiliates in accordance with its regular rates and terms. I acknowledge that I am responsible for any copay and coinsurance at the time of service. I understand that VIA Affiliates reserves the right to charge a fee for any checks returned for non-payment. X________________________________ Signature of Patient/Guarantor ______ Time Date Relationship to Patient If Patient is unable to sign, please state reason and initial Signature of Witness Time Date __________ I hereby acknowledge that I have read this form and have had the opportunity to ask questions Initials and had them answered. Doylestown Clinical Network (DCN) The DCN is a database created by all the physicians in the Doylestown community who have some category of membership on the Medical Staff of Doylestown Hospital. The database consists of patient medical records from participating practices in the Doylestown community. The only physicians allowed to access your records are those who are currently treating you. The DCN is designed to enhance the quality of care provided to you and reduce the risk that you will be prescribed inappropriate or excess medications. When registered as a patient in this Practice, and by signing this form, you are automatically included in the DCN. The Practice will include all of your clinical information including medical history, diagnosis, allergies, medications, results, plan of care, etc., in the DCN so it will be available to any physician member of the DCN who is treating you. All of your medical information will be put into this network, including anything related to drug/alcohol treatment, sexually-transmitted diseases, HIV status, and psychiatric care and treatment. This information is available to participating referring physicians and clinicians at any time they are providing you with care and/or in the event of an emergency visit. If you do not want other physicians to have access to all of this information, and choose not to participate in the DCN, ask our registration staff for the Opt-out form. Once you have completed and signed the form, your information will not be shard on the DCN. You may opt-out of the DCN at any time by simply telling any of our staff members of your decision. I hereby understand and agree with the sharing of my clinical data for the purpose of my treatment and care on the Doylestown Clinical Network (DCN). X Patient Signature Parent/Guardian Signature Print Patient Name Date