FAMILY INTERNAL MEDICINE OF OCALA,

[Pages:12]FAMILY INTERNAL MEDICINE OF OCALA, LLC Adult Patient Medical Questionnaire

Date:

Name:

LASi

Home Address:

STREEI

Gender: fl Fennle tr Male llrrefttrE SS #:

Patient Email:

Dayfre

Date of Birth:

MM,IDD/CCYY

silff

CdPttrE

-.zF

Ethnic Group: E Declined to state E Hispanic or Latino tr Not Hispanic or Latino

Mtive Black Race: tl Afiilan Amrican or

tr Arneican Indian orAlaslo

tr Asian tr Declined to state tr Middle-Eastern

! Race ! tr Native Hawaiiary'OtherPacift Other

Pacific Islander tr White or Caucasian

Next of Kin (for emergency):

Name of spouse or parent:

Day Phone:

Referred by:

Insurance: Name

Phone #

Policy#

Group #

List any current medicol problems or conditions.

1)

7)

2\

8)

e)

10) 11)

t2)

List ony allergies to medication, x-ray dyes, or food. Allergv

Reaction

Local

MailOrder Pharmacu

List any medicotion thot you currently toke, including over-the-counter.

Name

Strenoth

Direction

Prescribed bv

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Patient Name:

Date of Birth:

Antibiotic Prophylaxis Medication

1)

2l

Childhood Illnesses 1)

Chronic Illnesses

1)_ __ 2)_

Last EyeEnm: Last Dental Exam:

Condition

4l

3) 4)

Medication 3) 4)

5) 6)

s) 5)

Accidents

Injury

Date

1)

2l

Past Surgeries Surgery

Date

1)

2)_ 3)__

Injury

Surgery 4) s) 5)

List Anv Other Hospital Stays:

Reason

1)

4l

2)

s)

3)

5)

Anesthesia History

Any problems with anesthesia? tr ruO n VES (lf yes, please list)

Reason

Condition

Date Date Date

List Any Procedures Procedure

1) 2) 3)

Date

Physicians/Practitioners You Currently See:

Name

Specialty

1)

2)

3)

Procedure

4l

6)

Name

Date Specialty

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Poge 3

Patient Name:

Please list ony heolth problems and couses of death if opplicobte.

Family Member

Age

Father Mother Brother(s)

Date of Birth:

History

Sister(s)

Mother's father Mother's mother Father/s father Father's mother

No Do you drink alcohol?......................fl

E Yes

lf yes, how much?

n No Are you sexually active?..................n

yes

lf yes, whot form of controception

n Do you consume caffeine?............f] trto yes

lf yes, how much per doy?

Diet flBalanced fJVegetarian EDiabetic nLow Salt

ELow Fat nlow Carb EOther:---

Have you ever been in an

n abusive relationship?.......................8 ruo Yes

Are you afraid of your partnerZ...n ruo D yes Education: nHign School ncollege nsome College

ETrade School EOther: Do you do some form of

n regular exercise every day?...........E ruo Yes

lf yes, how much?

Marital Status: IMarried Esingle EDivorced

Ewidowed nother:

Occupation: Place of Birth (City, State);

Haveyou lilred abroad morctran one monh?..... Eruo nYes

lf yes, where? List everyone in your household, including pets:

Do you wear seatbelts?................... Eruo.nYes

Do you participate in any activities that

put you at risk of getting AIDS?...................... nUo EYes

Do you smoke or chew tobacco:....... f]trto f]Yes

lf yes, how much:

Spouse's occupation:

Do you use recreational drugs:..... _ lf yes, whot do you use?

Ewo nYes

Pleose record the last year you hod the following. lf you do not know, leove blank.

Flu vaccine (shot)........................ Pneumonia vaccine (shot) ..... Tu berculosis Test........................... Positive PPD................. Tetanus Diphthaia vaccine (shot)....

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Patient Name:

Date of Birth:

Date of last menstrual period:

Amount: E Normal tr t-igfrt E Heavy n Other:

Duration: days

Are periods regular?

n ruO I YfS

How many days apart are periods?

Age of onset of period:

Age of cessation of periods:

Any abnormal PAP smears? n NO n YES

lf yes, when

Diagnosed with any STD's? n ruO E VfS

lf yes, what

Please note the number of:

Total Pregnancies: ...................... Full term births:

Premature births:

Abortions - induced: Abortions - spontaneous:........ Pregnancies - Ectopic............... Pregnancies - Multiple births:

Living; ............

Please check if you have hod probtems with o, or" pr"r,"ntly experiencing problems with ony of the fottowing:

Skin

n stin diseases

Eyes

E Eyes diseases

ENT

n Hay Fever n Head or neck

Neck

n

Respiratory

n Shortness of breath

E Asthma E Bronchitis

n Pneumonia

E Persistent cough

Cardiovascular

tr Higir blood pressure E Heart disease n Chest pain n Swollen ankles n Palpitations n tightheadedness

Gastrointestinal

E Abdominaldiscomfort E Indigestion E Nausea

n Vomiting

E Constipation E Diarrhea

n alood in stool

E Ulcers n Change in bowel habits E Unexplained weight gain/loss

fl Hemorrhoids n Catt bladder disease n cotitis

Genitourinary (Female)

E Frequent urination E ridney diseases

n ridney stones

E Difficulty urinating

Genitourinary (Male)

n Frequent urination n fidney diseases n ridney stones

E Difficulty urinating

n I Do you have an advanced directive (living will)? ruo Yes

Notes:

Musculoskeltal

n Rrthritis E Low back problems

E Gout

Neurological

I Headache

Endocrine

! Diabetes

E Thyroid disease

Psychiatric

n Anxiety fl Depression

E Alcohol abuse E Drug abuse

Hematologic/Oncologic

n Cancer I glood disorders

E Anemia

Infectious Disease

E Venereal diseases

n Hepatitis or Jaundice n r.e. f] Rheumatic fever

Breast

tr

Authorized Signature: Reviewed by:

Date: Date:

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FAMILY INTERNAL MEDICINE OF OCALA, LLC Patient Consent for Use and Disclosure of Protected Health Information

With my consent, Family Intemal Medicine of Ocala, LLC may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPS). Please refer to Family lnternal Medicine of Ocala, LLC's Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent.

Family Intemal Medicine of Ocala, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Family Internal Medicine of Ocala, LLC Privacy Officer at 1623 SW 1't

Avenue, Ocala, FL 3447 l.

With my consent Family Internal Medicine of Ocala, LLC may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Family Intemal Medicine of Ocala, LLC may mail to my home or other designated location any items that assist the practice in carrying out TPS, such as appointment reminder cards and employee statements as long as they are marked Personal and Confidential.

By signing this form, I am consenting to Family Intemal Medicine of Ocala, LLC's use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made

disclosures in reliance upon my prior consent. If I do not sign this consent Family Internal Medicine of Ocala, LLC may decline to provide treatment to me.

Signature of Patient or Legal Guardian Printed Name of Patient or Legal Guardian

Date

FAMILY INTERNAL MEDICINE OF OCALA, LLC AUTHORIZED REPRESENTATTVE FORM

Note: This form is used to confirm a Patient's permission that Family Internal Medicine of

Ocala, LLC may discuss or disclose their protected health information to a particular person who acts as their Authorized Representative. Use of their information is strictly limited to that pu{pose described above.

SECTION A: Patient Information

By signing this form in Section E below, I understand that Family Internal Medicine of Ocala, LLC may release my personal health information as defined in Section B below to my Authorized Representative(s) named in Section C below.

Patient Name:

Address:

Telephone Number:

Social Security Number:

Please note: This authorization does not provide you're "Authorized Representative" with any authority, either implied or direct, over any treatment or direct care decisions. IF you wish to

designate a health care partnerlproxy or a clinical personal health care rq)resentative or if you want to set up a living will, please discuss this with your primary care physician or your attomey. Also, we promise that we will not condition treatment on the execution of this form.

SECTION B: Tlpe of lnformation

Personal Health Information, including but not limited to, billing information, diagnosis, procedures, dernographic information (but not including any psychotherapy notes).

SECTION C: Authorized Use/or Disclosure

Intended use or disclosure: I understand that your general policy is not to disclose my personal health information to other parties, except those directly involved in my care, without my written authorization or as permitted or required by law. For this reason, I authorize you to discuss and

disclose my personal health information to the person(s) named below for the purpose of

assisting with, or facilitating, the coordination or payment of my health care. I also understand that if my Authorized Representative is not a health care provider or another entity subject to federal or applicable state and privacy laws and my personal health representative may further disclose my personal health information without my authorization.I acknowledge that my

authorization is voluntary.

Authorized Representative # 1

Name:

Phone Number:

Address:

Relationship to you:

Authorized Representati v e #2

Name:

Phone Number:

Address:

Relationship to you:

I understand that I have the right to limit the information that you release under this authorization. For example, I may limit my Authorized Representative's access to information about a particular health care provider or a particular diagnosis/disease. Any such limitation must be described below in writing.

I understand that by leaving this section blankr l am creating no limitations on disclosure.

(initial).

Limitations on disclosure:

SECTION D: Expiration and Revocation

This authorizationto release information to my Authorized Representative will automatically

expire two (2) years following my death.

I understand that I have the right to revoke or end this authorization at any time. I understand

that, if I do not wish the person(s) named in Section C to remain my Authorized Representative, I must revoke this authorizationin writine by giving notice of my decision to Family Internal Medicine of Ocala, LLC contact below. I understand that my revocation of this atthoization will

not affect any action that you have taken, or any information that you have already released, based upon this authorization before you actually receive my request to revoke it.

Contact: HIPAA Compliance Officer

Address: 1623 SW l't Avenue Ocala, FL3447l

SECTION E : Si grrature/Authorization

I have had full opportunity to read and consider the content of this Authorized Representative Form. I confirm that this authorization is consistent with my request of Family Internal Medicine of Ocala, LL. I understand that, by signing this form, I am confirming my authorization that Family Internal Medicine of Ocala, LLCmay use and/or disclose mypersonal health information to the person(s) named in Section C for the purpose described above.

Signature of Patient

Date

You are entitled to a copy of this Authorization Form after you sign it.

FAMILY INTERNAL MEDICINE OF OCALA, LLC

Patient Rights and Responsibilities

In recognition of our responsibility in rendering patient care, these rights and responsibilities are affrmed in the policies and procedures of Family Intemal Medicine of Ocala, LLC and Internal Medicine Associates of Ocala, LLC.

The patient has the right to:

o Be treated with courtesy and respect, with appreciation of his or her individual dignity and with protection of his

or her privacy.

o Prompt and reasonable response to questions and requests. o Know who is providing medical services and who is responsible for his or her care. o Know what patient support services are available, including whether an interpreter is available if he or she does

not speak English.

o Know what rules and regulations apply to his or her conduct. o Be given infonrration conceming the diagnosis, the planned course of treatment, alternatives, risks, and prognosis

by the health care provider.

o To refuse treatment, except as otherwise provide by law. e Be given, upon request, fuII information and necessary counseling on the availability of financial resources for his

or her care.

o Know, upon request and in advance of treatment, whether the healthcare provider or healthcare facility accepts the

Medicare assignment rate.

o Receive, upon request and prior to treatment, a reasonable estimate of charges for medical care. o Receive a copy of a reasonably clear and understandable itemized bill and upon request to have charges

explained.

o Receive impartial access to medical treatment or accommodations, regardless of race, national origin, religion,

physical handicap, or source ofpayment.

o Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment. o Know if medical treatment is for purposes of experimental/research and to give his or her consent or refusal to

participate in such experimental research.

. Express grievances regarding any violation of their rights, as stated in Florida law, through the grievance

procedure of the healthcare provider or healthcare facility that serviced them and to the appropriate state licensing

agency.

o Participate in all aspects of their health care decisions, unless contraindicated by concerns for their health. . Appropriate assessment and management of pain. o For providing to the healthcare provider, to the best of his or her knowledge, accurate and complete information

about present complaints, past illnesses, hospitalizations, medication, and other matter relating to his or her

health.

o For reporting unexpected changes in his or her condition to the healthcare provider. o For reporting to the healthcare provider whether he or she comprehends a contemplated course of action and what

is expected ofhim or her.

o For following the treatment plan recommended by the healthcare provider. o For keeping appointments and for notiffing the Facility when he or she is unable to do so for any reason. o For his or her actions if he or she refuses treatment or does not follow the healthcare provider's instruction. o For assuring that the financial obligation of his or her healthcare are fulfilled as promptly as possible. o For following facility rules and regulation affecting patient care and conduct. o For consideration and respect ofthe facility staffand property. o Telling the Center personnel about living will, medical power of attorney, or other documents that could affect

their care.

'!a _

Patient or Guardian Signature

Date

Patient or Guardian Printed Name

 ................
................

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