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
Ver.3.0_0522L2
Poge 2
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
Yer.3.0_052212
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)....
Ver.3.0 0522L2
Poge 4
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:
Ver. 3.0-052212
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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