Download Jerrold S. Canakis, MD

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Dental emergency wikipedia, lookup

Medical ethics wikipedia, lookup

Electronic prescribing wikipedia, lookup

List of medical mnemonics wikipedia, lookup

Transcript
Jerrold S. Canakis, M.D., P.A.
10344 Old Ocean City Blvd, Suite 1
Berlin, MD 21811
Patient Information
Patient Name ______________________________
SSN _____________________________________
Home Address _____________________________
__________________________________________
Mailing Address ____________________________
__________________________________________
Primary Physician ___________________________
Referring Physician __________________________
Name of Insurance Company ___________________
Name of Policy Holder ________________________
Patient’s Relationship to Policy Holder ___________
Policy Holder’s Date of Birth ___________________
Today’s Date ______________________________
Home Phone # _____________________________
Work Phone #______________________________
Cell Phone # ______________________________
Patient’s Sex Male ___ Female ___
Date of Birth ______________________________
Employer _________________________________
Employer’s Address _________________________
Occupation ___________________________
E-mail address _____________________________
Marital Status: Single Married Divorced Widowed
We are now required by the federal government to collect the following information through the
electronic medical record. Please circle the appropriate responses.
Race
Native Hawaiian
Other Pacific Islander
Black/African American
American Indian/Alaska Native
White
More than 1 race
Unreported/Refused to report
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Unreported/Refused to report
Language
Arabic
Chinese
Chinese (Cantonese)
Chinese (Mandarin)
English
Filipino
French
Greek
Italian
Japanese
Korean
Other ______________________
Spanish
Vietnamese
CONTACT CONSENT
I hereby authorize Dr. Canakis and his staff to speak to the following people regarding my healthcare. The first
person listed is my emergency contact.
Name:________________________________ Relationship:________________ Phone:___________________
Name:________________________________ Relationship:______________________________
Name:________________________________ Relationship:______________________________
Signature:__________________________________________ Date:_________________________________
Revised 11/6/14
Jerrold S. Canakis, M.D., P.A.
Gastroenterology
10344 Old Ocean City Blvd, Suite 1
Berlin, MD 21811
Office: 410-641-2938
Fax: 410-641-4904
Patient Consents
HIPAA POLICY: I have been given access to, and have read, the HIPAA policy for Dr. Canakis’ practice.
Signature: ________________________________________ Date:________________________________
Assignment of Benefits:
I hereby authorize my insurance company(s) to make payment(s) as stipulated in
my policy for any services furnished and that such payment(s) be paid directly to the provider of the service. I
also understand that I am financially responsible for all services provided and agree to pay upon demand or as
agreed for the related charges or remaining charges following my insurance payment(s).
I understand all co-pays will be collected at the time of service. All prior balances must be reconciled either by
mail prior to, or at, my next visit, whichever is sooner. The office accepts cash, check, VISA and MasterCard.
A $25.00 returned check fee will be applied to my account for all returned checks.
The undersigned acknowledges that if his/her account becomes delinquent (over 120 days past due) and is
referred to our attorney for collection, then in such event, the undersigned agrees to pay an additional 33.33% of
the outstanding balance, which represents reasonable attorney fees for the collection of the account, and in
addition, agrees, acknowledges and understands that the undersigned will be responsible to pay all court costs
expended in an effort to collect the delinquent account. In addition, if any suit must be filed to collect an unpaid
balance on an account, patient, and/or guarantor, agrees that such suit may be brought in courts of Worcester
County, Maryland, and waives any objection to jurisdiction or venue.
I understand I may be charged a fee if I miss my appointment or do not cancel at least 24 hours prior to my
appointment. This fee is not covered by my insurance carrier and must be paid prior to my next appointment.
Signature: ________________________________________ Date:__________________________________
Allscripts Medical Community Consent:
I hereby authorize Dr. Canakis and his staff to access my medical records electronically from Atlantic General
Hospital and my other physicians when appropriate and available.
Signature:
Date:___________________________________
Revised 11/6/14
________________________________________
PATIENT MEDICAL INFORMATION
Name:_______________________________________
Date of Birth:______________________________
Reason for your visit today: __________________________________________________________________
Have you had any labs/radiology tests regarding this problem? If so, what and where?___________________
_________________________________________________________________________________________
Who referred you today:_____________________________________________________________________
Local Pharmacy ___________________________________Mail Order Pharmacy_______________________
Medications (Prescription and over the counter vitamins and supplements):
Name
Reason you take it
Name
Reason you take it
_____________________________________
_________________________________________
_____________________________________
_________________________________________
_____________________________________
_________________________________________
_____________________________________
_________________________________________
Please use back of form if needed.
Medication Allergies:
Name
Reaction_________ __
______________________________________
______________________________________
Name
Reaction_________
_________________________________________
_________________________________________
Surgical History (Please list your surgeries and approximate year performed):
______________________________________
_________________________________________
______________________________________
_________________________________________
______________________________________
_________________________________________
Family History (Has anyone in your family had these conditions and if so, who):
Colon cancer……..No/Yes….Who_____________
Liver cancer……..No/Yes……Who_______________
Colon polyps………No/Yes…..Who_____________
Crohn disease…..No/Yes……Who_______________
Celiac disease…….No/Yes…..Who_____________
Colitis……………….No/Yes……Who_______________
Pancreatic cancer…No/Yes……Who____________
Stomach cancer…..No/Yes….Who_______________
Esophageal cancer/Barrett esophagus……..No/Yes……Who________________
Social History:
Marital status: Single Married Separated Divorced Widow/Widower
Occupation: Currently employed N/Y Employer__________________________________________________
Student
Retired
Unemployed
Tobacco: Never smoker
Current smoker #PPD ______ #YRS______
Previous smoker Quit _________
Alcohol: None Socially Daily # per day _______ Recovering alcoholic
Illicit drug use: Never used
Currently use
Previously used
Have you ever had a colonoscopy? _______ When?________ Findings _______________________________
Have you ever had an upper endoscopy? ________ When? ________Findings __________________________
Do you have an AICD (an implanted defibrillator)? _________
What medical providers would you like your notes to be sent to?_____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________________rev 6-20/14
Review of Systems
Please complete this form every time you come for an office visit with us. Please circle those
responses that correspond to how you have been feeling the last 2 to 3 weeks, even if it is
something that you have all the time. We need to enter this information into the computer.
Thank you for your cooperation. 
General
Feeling well
Appetite loss
Fatigue
Fever
Night sweats
Weight gain
Weight loss
Skin
Bruising
Dryness
Itching
New lesions
Rash
Skin color changes
HEENT
Headache
Blurred vision
Hearing loss
Nosebleeds
Cold
Seasonal allergies
Sleep apnea
Neck
Pain
Stiffness
Swollen glands
Gastrointestinal
Abdominal pain
Belching
Black, tarry stool
Bloating
Bloody stool
Change in bowel habits
Constipation
Diarrhea
Difficulty swallowing
Heartburn
Jaundice
Nausea
Painful swallowing
Rectal bleeding
Vomiting
Vomiting blood
Musculoskeletal
Back pain
Calf pain
Joint pain
Muscle cramps
Neurologic
Dizziness
Numbness
Weakness
Psychiatric
Anxiety
Depression
Change in sleep pattern
Mood Changes
Endocrine
Cold intolerance
Excessive thirst
Excessive urination
Heat intolerance
Respiratory
Cough
Difficulty breathing
Coughing up blood
Snoring
Wheezing
Cardiovascular
Chest pain
Shortness of breath
Swelling of extremities
Hoarseness
Oral ulcers
Sore throat
Choking sensation
Difficulty chewing
Yellowing of eyes
Hematology
Easy bruising
Easy bleeding
Enlarged lymph nodes
Prolonged bleeding
Have your medications changed since last visit? ______ If so, what has been discontinued or
added? ___________________________________________________________________
_________________________________________________________________________
Have you had surgery since your last visit? ______. When?_____. Where? ______.
Have you been to the ER since your last visit? _____. When?______. Where?______.
Which pharmacy would you like your prescriptions go to today? ________________________
Name ____________________________E-mail ________________________ Date__________