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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PATIENT INFORMATION Patient Name_______________________________________________________________________________ Last First Middle Initial Address___________________________________________________________________________________ Street City State /Zip Code Telephone_________________________________________________________________________________ Home Work Cell Social Security # _________________________________ Male_________ Female_________ Date of Birth_________________________ Marital Status: Married__ Single__ Widow__ Divorced__ Pt Email Address_______________________________________@__________________________________ Emergency Contact_________________________________________________________________________ Name / Relationship Phone Number Email Address _________________________________________@__________________________________ Hospital____ Doctors Office____ Referral___ New Visit____Other _________________________________________________________________________________________ Where did you previously meet Dr. Shahzad? Primary Care & Referring Physician__________________________________Telephone_____________________ Pharmacy:____________________________ Phone: _________________________________________ EMPLOYER Company____________________________________________Occupation_________________ _______ Address:____________________________________ Phone_______________ � Full-time � Part-time City _________________________ State _____________ Zip__________ Years Employed______________ Are your present symptoms or conditions related to or the result of an auto accident, workrelated injury or other personal injury someone else might be legally liable for? � Yes � No Your Initials:__________ If you answered yes, please fill out accident specific form, available at the front desk. 5 INSURANCE Please list any and all insurance and/or employee health care plan coverage you or your spouse may have Insurance Company or Health Care Plan Name__________________________________________________ Policy/Group #:______________________________________ Effective Date:_______________________ Name of Insured: ______________________________________ ID #:______________________________ COINSURANCE Please list any and all coinsurance and/or employee health care plan coverage you or your spouse may have Insurance Company or Health Care Plan Name__________________________________________________ Policy/Group #:______________________________________ Effective Date:_______________________ Name of Insured: _______________________________________ ID #:______________________________ I authorize AHVC to contact me in the following manner: (Please check all that apply) HOME PHONE____ WORK PHONE____ CELL PHONE ______ Text Message______ Email_______ ( ) You may leave messages on my answering machine or voice mail with detailed message. ( ) You may leave messages identifying the practice/physician and leaving a call back number only. ( ) You may leave messages with a family member (Please identify by name and relationship below). _____________________________________________ 6 NAME: ____________________________________________ DOB:_________________ Check all that apply Yes Past Medical History No Don’t Know Coronary Artery Disease Heart Attack Cardiac Arrest Angioplasy or Sent of Heart Arteries Coronary Artery Bypass Peripheral Vascular Disease (PAD or PVD) Angioplasy or stent of Leg Arteries Carotid Stenosis (Blockage) Carotid Artery Surgery or Stent Abdominal Aortic Aneurysm Stroke Atrial Fibrillation or Atrial Flutter Diabetes High cholesterol High blood Pressure Pacemaker Placement Defibrillator Placement Congestive Heart Failure Asthma COPD Blood Clots in Lungs (Pulmonary Embolism) Blood Clots of Leg Veins (DVT) Thyroid Abnormalities Any other significant Medical or Surgical History Yes Family History Heart Attack Heart Sent or Bypass Surgery Sudden Cardiac Death Stroke Carotid Artery Surgery Congestive Heart Failure Any other Significant Heart History Pacemaker Placement Cancer 8 No Relationship Social History: Alive Deceased Father ( ) ( ) Present health or cause of death Mother ( ) ( ) Present health or cause of death Brothers No. alive/Health No. Deceased Cause of death Sisters No. alive/Health No. Deceased Cause of Death Children No. alive/Health No. Deceased Cause of Death Are you married? Do you currently smoke? Have you ever been a smoker? Do you currently drink alcohol? Do you use recreational drugs? Do you exercise? Do you drink caffeine ( ( ( ( ( ( ( ) YES ) YES ) YES ) YES ) YES ) YES ) YES ( ( ( ( ( ( ( ) NO ) NO How many cigarettes/day ________ ) NO How many/day_____ How long __________ ) NO How much _______ How often _________ ) NO ) NO How often____________________________ ) NO How much_____________________________ Occupation: _____________________________________________________________________________ Recent Hospitalization/Surgeries: ( ) YES ( ) NO If Yes, please specify When, Where and the Reason for Hospitalization/Surgery: _____________________________________________________________________________________________ Allergies to any Medications: ( ) YES ( ) NO If yes, please list the name of medications and type of reaction you had: Allery to Iodine Dye: ( )YES ( )NO ( ) Don’t Know If yes please describe the kind of reaction you had to dye exposure: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 9 Please List all of your current medications, prescription and over the counter : 10