PatientPop



> Complete Entirely or Indicate N/A > Print Clearly and Sign AuthorizationName:_______________________________________________________ Date of Birth:______/______/______ (Last) (First) (MI)Sex: ________ Marital Status: _________ Social Security Number: __ __ __ - __ __ - __ __ __ Email Address: _________________________________________ Home Phone: _________________________________ADDRESS: Cell Phone: __________________________________Street:_____________________________________________________________________________________________City: _________________________________ State: ____________ Zip: ______________(Circle One)EmployedRetired Part Time Student Full Time StudentEmployer: __________________________ School: _________________________ Occupation: _____________________**Primary Care Physician/Pediatrician: __________________________________________________________________**Pharmacy Information _____________________________________________________________________________ (Name) (Phone # / Cross Streets)Parents (Responsible Parties)Self/Parent: ___________________________________Date of Birth: ____/____/____ SS# _____ - ____ - _____Home#: ______________ Work#: __________________Address: ______________________________________City: ________________ State: ______ Zip: __________Employer: _____________________________________Parent/Spouse: ________________________________Date of Birth: ____/____/____ SS# _____ - ____ - _____Home#: ______________ Work#: __________________Address: ______________________________________City: ________________ State: ______ Zip: __________Employer: _____________________________________Insurance InformationSpecialist Co-Pay $ ________ PrimaryName: _______________________________ID#: _________________ Group#: _________Address: _____________________________Phone#: _______________________________Cardholder’s Name: _____________________DOB: ____/____/____ SS# _ _ _ - _ _ - _ _ _ SecondaryName: _______________________________ID#: _________________ Group#: _________Address: _____________________________Phone#: _______________________________Cardholder’s Name: _____________________DOB: ____/____/____ SS# _ _ _ - _ _ - _ _ _ Patient Communication & AuthorizationEmergency Contact: ___________________________ Relationship: _________________Contact#: ( )_____________ THE FOLLOWING PERTAINS TO THE ABOVE-NAMED PATIENT (CHECK ALL THAT APPLY) Okay to call Home and Leave Messages Don’t Call Home Phone Okay to Call Work Number Call Work Number Only Don’t Call Work NumberOTHER THAN YOURSELF, TO WHOM MAY WE RELEASE YOUR PROTECTED HEALTH OR BILLING INFORMATION?INITIAL MEDICAL HISTORYDate: _____/_____/_____To our Patients:Thankyou for completing the following confidential history form. It will help us greatly in the overall evaluation of your health care. We will develop your history further in the examination room. If you have any questions, please don’t hesitate to ask. MALE Name: ____________________________________________ Age: _______ Date of Birth: ____/____/____ FEMALE (Last) (First) (MI)Referred to this office by: ______________________________ Currently under the care of a physician? Yes NOIf Yes, Whom? _______________________________________ For what diagnosis? ______________________________For what problem did you come to see the doctor today? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you been treated for an ear, nose or throat problem before? Yes No M.D.’s Name: __________________If Yes, Describe the previous problem: ___________________________________________________________________Are you currently using tobacco? Yes No If yes, how much? _______________ How Long? _________________If no, have you ever used tobacco? Yes NoIf yes, how much? _______________ How Long? _________________ When did you quit? ________________________History of drug abuse? Yes No History of alcohol use? Yes No If yes, How much? _______________Any past history of: (if YES, please check and elaborate briefly below.) Asthma Hay Fever Eczema Diabetes Ulcers Alcoholism Heart Trouble Liver Trouble/Hepatitis Tuberculosis High Blood Pressure Kidney Disease Eye Disease Nervous Disorder Bleeding Disorder Bruising Easily HIV OtherExplain: ____________________________________________________________________________________________________________________________________________________________________________________________________I Certify that all the information listed above is, to the best of my knowledge, true and correct. Patient Signature ___________________________________________________ Date ____/____/____Reviewed and confirmed by ___________________________________________ Date ____/____/____Patient Name: _____________________________________________________ DOB: _____/_____/_____Have you experienced any of these problems during the past several months?You can write in additional information about these symptoms below.GeneralUnexplained fevers Yes NoWeight gain _____lbs Yes NoWeight loss _____lbs Yes NoNew or severe fatigue Yes NoEyesNew vision problems Yes NoNew double vision Yes NoEar/Nose/Mouth/ThroatPain or problems swallowing Yes No New hearing loss Yes NoNew dizziness Yes NoHeart-RelatedChest Pain Yes NoLeg swelling Yes NoLightheadedness with activity Yes NoLung-RelatedNew cough Yes NoPain with Breathing Yes NoNew shortness of breath Yes NoBone and Muscle-RelatedNew back pain Yes NoNew bone pain Yes NoEndocrineUnusual thirst Yes NoBrittle hair Yes NoUnusual amount of urination Yes NoGastro-Intestinal Rectal bleeding Yes NoNew diarrhea Yes NoNew constipation Yes NoHeartburn or severe indigestion Yes NoGenito-UrinaryExcessively frequent urination Yes NoPain with urination Yes NoBlood in urine Yes NoAbnormal/new vaginal bleeding Yes NoPain with pelvic exams Yes NoSkinNew rash Yes NoNew skin spots of concern Yes NoBrain and nerve-relatedNew headaches Yes NoSeizures or unexplained fainting Yes NoArm or leg numbness or weakness Yes NoNew bladder or bowel incontinence Yes NoHematologic/LymphaticNew easy bruising Yes NoNew swollen glands Yes NoAllergies and Immune SystemRecurrent Infections Yes NoLife-threatening allergies Yes NoPsychiatricDisabling feelings of depression Yes NoTrouble sleeping Yes NoDisabling feelings of anxiety Yes NoPatient Name: _____________________________________________________ DOB: _____/_____/_____I have had the following surgeries in the past (Surgery Type and Approximate Year):____________________________________________________________________________________________________________________________________________________________________________________________________I have been diagnosed with the following medical conditions/hospitalizations (condition and Approx. year):____________________________________________________________________________________________________________________________________________________________________________________________________I have a family history of the following medical conditions (Mother, Father, Siblings):____________________________________________________________________________________________________________________________________________________________________________________________________Do you have any known allergies to medications?____________________________________________________________________________________________________________________________________________________________________________________________________Please list all current medications -OR- See AttachedMEDICATIONDOSAGEFREQUENCYREASON TAKENACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICENotice to patient:We are required to provide you with a copy of our Patient Rights and Responsibilities and Notice of Privacy Practices, which states how we may use and /or disclose your health information. Please sign this form to acknowledge receipt of the notice. I acknowledge that I have received a copy of this office’s Notice of Privacy Practices. Patient Signature: __________________________________________ Date: _____/_____/_____CONSENT TO BE TREATED BY:Oasis Ear, Nose and ThroatConsent for Treatment/Care:I consent to treatment and care by Oasis Ear, Nose and Throat and by their physicians and health care providers, including those who are located at sites other than the one at which I am present and who provide treatment and care through electronic communications. I understand that my treatment and care may include routine care, such as assessments, medications, and a variety of other medical services depending on my condition, such as laboratory testing. I can receive a list of services and care from my health care provider. I understand that my care team at Oasis Ear, Nose, and Throat may include resident physicians and students or other trainees. I am aware that the practice of medicine (including surgery) is not an exact science, and no one has made any guarantees about the results of my treatments, payments, examinations, or procedures. I acknowledge that I have received a copy of the Consent for Treatment, and that I am agreeing to its explanation.Patient Signature: __________________________________________ Date: _____/_____/_____Patient Rights and ResponsibilitiesYou have the right to:Be treated with dignity, respect and considerationNote be discriminated against based on race, age, gender, national origin, religion, sexual orientation, disability, marital status or diagnosis. To receive privacy in treatment and care for personal needs. To receive treatment that supports and respects your individuality, choices, strengths and abilities.Not be subjected to misappropriation of personal and private property by your provider or its staff. To review upon written request, your medical record. Safe care and not be subjected to neglect, exploitation, coercion, manipulation, abuse (physical, sexual, emotional) or sexual assault.Know the identity of those professionals that are treating you.Participate or have your representative participate in the development of, or decisions concerning, treatment. To receive a referral to another provider if our clinic cannot provide services needed.Refuse or withdraw treatment to the extent permitted by law including research or experimental treatment.Receive explanation prior to any transfer of care.Have assistance from a family member, representative of other individual in understanding, protecting, or exercising your rights. File a complaint with a manager, the Department of Health Services, or your provider without retaliation.Understand why someone is involved or observing care.Not be restrained or secluded.Receive, on request, information about schedule of rates, charges, explanation of bill, regardless of source of payment.Consent to photographs before one is taken, except for photos taken for identification / administrative purposes.Have an advanced directive concerning treatment. Except in an emergency, provide you with alternative to a proposed psychotropic medication or surgical procedures along with any associated risks and possible complications of the proposed treatment.You have the responsibility to:Provide accurate & complete information concerning present complains, past medical history, and other matters relating to his/her health.Make it known whether you clearly comprehend the course of treatment and what is expected of him/her.Follow the treatment plan established by his/her physician, including the instructions of nurses and other health care professionals, as they carry out the physician’s orders. Keep appointments, notify Oasis, Ear, Nose and Throat of physician when unable to do so.Accept responsibility of your actions should you refuse treatment or not follow physician's orders.Assure that financial obligations of your care are fulfilled as promptly as possible. Follow AZCCC policies and procedures.Be considerate of the rights and property of other patients and facility personnel. Notify the AZCCC staff of request for interpreter services. If you have any comments or concerns regarding services provided by Arizona Center for Cancer Care, please contact our site Administrator at (480) 278-8862 or write to us at, 14155 N 83rd Avenue, Suite 127, Peoria AZ 85381. If you are still not satisfied or have further concerns, you may file a complaint with the AZ Department of Health. ................
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