Download Patient Information Form

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.
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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).
_____________________________________________
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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
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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:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Please List all of your current medications, prescription and over the counter :
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