Download PATIENT INFORMATION FORM

PATIENT INFORMATION FORM
The following information is very important to your health. Please take time to fully and completely fill out this important
information. We are counting on you.
PATIENT INFORMATION (please print)
SPOUSE OR PARENT INFORMATION
NAME:
________________________________
NAME:
_____________________________
ADDRESS:
________________________________
ADDRESS:
_____________________________
________________________________
_____________________________
PHONE:
________________________________
PHONE:
CELL:
________________________________
If the insurance coverage is through the spouse or
ALTERNATE PHONE:
E-MAIL:
_________________________
________________________________
_____________________________
parent the following information is required:
DOB: ______________________________________
DATE OF BIRTH:
_________________________
EMPLOYER ____________________________________
OCCUPATION:
_________________________
BUSINESS PHONE ______________________________
Full Time
INSURANCE CO. ________________________________
/
Part Time
MARITAL STATUS:
_________________________
POLICY ID# ________________________________
SOCIAL SECURITY#:
_________________________
GROUP #
DRIVER’S LICENSE#:
_________________________
EMPLOYER:
_________________________
BUSINESS ADDRESS:
_________________________
PRIMARY PHYSICIAN:
_________________
_________________________
PHYSICIAN’S PHONE:
___________________
_________________________
PERSON WHO REFERRED YOU TO US:
BUSINESS PHONE:
INSURANCE COMPANY_________________________
__________________________________
____________________________________________
POLICY ID#
_________________________
GROUP ID #
_________________________
EMERGENCY CONTACT (relative, friend, or neighbor)
NAME:
________________________________
ADDRESS:
________________________________
________________________________
PHONE:
________________________________
RELATIONSHIP:________________________________
COMMERCIAL INSURANCE:
I hereby authorize payment of benefits directly to the attending physician. I hereby authorize the physician to release any information acquired in the
course of my examination and treatment to permit processing of claims for insurance reimbursement. A photocopy of this signature is valid as the
original. We will be happy to assist you with your insurance billing. Although an insurance claim is filed, the patient is responsible for the
account with us.
Signature of Patient or Representative: _________________________________
Date: _______________
Please have insurance cards available for copying. We will be happy to assist you with your insurance billing. Although an insurance claim
is filed, the patient is responsible for the account with us.
HISTORY
COMORBIDITIES (circle if you have any of the following):
Abdominal Hernia / Abdominal Skin Pannus (problems with the abdominal skin irritation because of excess skin) Alcohol Use /
Angina or Chest Pain / Asthma / Back Pain / Cholelithiasis (gallbladder diasease) / Mental Health Problems (like anxiety, bipolar,
psychosis) / Congestive Heart Failure / Depression / Deep Venous Thrombosis or Pulmonary Embolism /
Fibromyalgia / Functional Status (bedridden, wheelchair, cane, crutches) / GERD (heartburn, reflux disease) / Glucose Metabolism
(glucose intolerance, diabetes) / Gout / Hyperuricemia (increased uric acid) / Hypertension / Ischemic Heart Disease (Heart Attack,
myocardial infarction) / Hyperlipidemia / Liver Disease (fatty liver) / Lower extremity edema or swelling / Menstrual Irregularities /
Musculoskeletal Disease (Foot,Ankle,Knee Pains) / Obesity Hypoventilation Syndrome / Sleep Apnea / Peripheral Vascular Disease
(stroke, leg pain when walking) / Polycystic Ovarian Syndrome / Pseudotumor Cerebri / Psychosocial Impairment / Pulmonary
Hypertension / Urinary Incontinence (Leakage of Urine With Coughing, Sneezing, or Laughing) / Substance Abuse (of illegal or
prescription drugs) / Tobacco Use.
PROBLEM LIST
Please circle all symptoms you currently experience, or have experienced in the past few weeks. Feel free to add any additional
problems or information.
1.
HEAD, EYE, EAR, NOSE & THROAT: stuffy Nose – runny Nose – hay fever – sinus trouble – earache – headache – blurry
vision – double vision – haloes around lights – loss of night vision – buzzing in ears – ringing in ears – discharge from ear – loss
of hearing – dizziness – vertigo – loss of balance – sore throat – lump in throat – trouble swallowing – pain with swallowing –
hoarseness
2.
RESPIRATORY: cough – wheezing – shortness of breath at night – use of two pillows – blood in sputum – out of breath with
exertion – wake up at night short of breath – wake up at night coughing or choking – asthma – emphysema – bronchitis
3.
CARDIOVASCULAR: palpitations – pounding heart – skipping heartbeat – pains in chest – pains in neck – pains in arms –
squeezing of chest – heart attack – heart murmur – abnormal electrocardiogram – irregular heartbeat – high blood pressure – pain
in legs – cold feet – blue toes – blue finger – loss of pulse
4.
GASTROINTESTINAL: heartburn – nausea – vomiting – belching fluid in throat – burning in throat – food sticking in chest –
pains in stomach – burning in stomach – acid stomach – diarrhea – constipation – pain with bowel movement – blood in stools –
hemorrhoids – fissures – cramps – gassiness – irritable colon – colitis
5.
GENITOURINARY: pain with urination – trouble starting urine – trouble stopping urine – small urine stream – blood in urine –
kidney stones – bladder stones – kidney failure – nephritis – urinary tract infection – frequent urination – getting up at night to
urinate – leakage of urine with cough or sneeze
6.
♦
Men: discharge from penis – loss of erection – painful erection
♦
Women: vaginal discharge – vaginal bleeding – pain with intercourse – irregular periods
ENOCRINE (GLANDULAR): low thyroid – hyperthyroid – goiter – Grave’s Disease – thyroid Nodules – xray to thyroids –
diabetes – adrenal gland tumor – frequent flushing – frequent heavy sweating
7.
MUSCULOSKELETAL: pain in joints- selling of joints – redness of skin over joints – warm joints – fluid in joints – arthritis –
broken bones – sprains – low back pain – hip pain – knee pain – ankle pain – foot pain – flat feet – slipped disk – herniated disk –
sciatica
8.
NEUROLOGICAL: dizziness – vertigo – falling to the side – falling at night – numbness – tingling – pins and needles feeling –
weakness of any muscles – twitching of muscles – weakness of grip – shakiness – tremors – fainting – convulsions – fits – loss of
consciousness
9.
PHYCHOLOGICAL: nervousness – anxiety – depression – thoughts of suicide – suicide attempts – hospitalization for
emotional problems – psychiatric treatment – psychological counseling
MEDICATIONS (list all current medications that you are taking)
Name
Why taking
**** if more, put other medicines on back of form***
Dose
Date started
FAMILY HISTORY:
Weight
Diabetes
Heart
High
High
Disease
Blood
Cholesterol
Sleep
Degenerati
Apnea
ve Joint
Pressure
Stroke
Other
Disease
Mother
Father
Siblings
Grandpare
nts
Others
DIET HISTORY:
(1) Physician Sponsored Diets
Doctor Name
Date Started
Duration (months in Plan)
Type (Med, Diet, Inject)
Weight Loss
Dr.
Dr.
Dr.
Dr.
Dr.
Phen Fen
_______________
Xenical _______________
Fastin
_______________
Meridia
_______________
Redux
Other
_______________
Optifast
_______________
_______________
(2) Nutritionist Sponsored Diets
Name
Weight Watchers
Duration (months in Plan)
Date Started
Weight Loss
Nutrisystem
Jenny Craig
T.O.P.S.
Others
(3) Over The Counter Diets
Name
Duration (months in Plan)
Date Started
Weight Loss
Reaction
Comments
Atkins
Metabolife
Zenadrine
Exercise Program
Others
ALLERGIES:
Agent
Date
PREVIOUS SURGERY:
Procedure
Date
______________________________________________
Patient Signature
Procedure
Date
___________________________
Date
The above is true and correct to the best of my belief.
Note: At the time of your visit it is very helpful to review recent medical evaluations and any laboratory studies which you may have
had recently performed. Please bring copies with you or request that they be mailed or faxed prior to the date scheduled for
your consultation send them.