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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__________
