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