Download Doylestown Breast Surgery Patient Form

*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