H
H. BRUCE HAMILTON, MD -- PATIENT INFORMATION FORM
Patient Name _____________________________________________ D.O.B. ____________________________________________
Age __________ Sex: Male Female Pregnant? Yes No SSN______________________________________________
Address _________________________________________________ Telephone _________________________________________
City & Zip _____________________________ Email address _________________________________________________________
Referring Physician ________________________________________ Primary Care Provider ________________________________
Patient’s Employer ___________________________ Patient’s Occupation _____________________________________________
Patient’s Work Phone____________________ Emergency Contact Name & Number _______________________________________
Marital Status _________________________ Preferred Language____________________________________________________
Federal Regulations require us to ask your Race/Ethnicity. ( Asian ( Caucasian ( African American ( American Indian ( Hispanic ( Other
Reason for Visit
Reason for visit or chief complaint ________________________________________ Duration of Symptoms______________________
Is the condition you are being seen for today in any way related to an on-the-job injury? ______________________________________
Medications / Allergies
Current
Medications ______________________________ ________________________ _________________________________
________________ ______________________________ ________________________ _________________________________
________________ ______________________________ ________________________ _________________________________
________________ ______________________________ ________________________ _________________________________
Pharmacy _______________________________________________ Phone ______________________________________________
Drug Allergies, including antibiotics: ( None or ______________________________________________________________________
( I am allergic to Contrast Dye ( I am allergic to Iodine Are you currently on blood thinner?(i.e. Plavix, Coumadin or Ticlid) ____________
PAST MEDICAL HISTORY
Please check where appropriate and explain when needed.
Nervous System HEENT Cardiovascular Pulmonary Gastrointestinal
π Paralysis π Glaucoma π Heart disease π Asthma π Hepatitis
π Seizures / Epilepsy π Blindness π Murmur π Emphysema π Liver disease
π Migraines π Blurry vision π Chest pain π COPD π Gallbladder disease
π Stroke π Difficulty swallowing π High blood pressure π Bronchitis π Ulcers
π Ringing in ears π Valve disease π Pneumonia π Colitis
π Hearing loss π Heart attack π Tuberculosis π Diarrhea
π Voice changes π Palpitation π Constipation
Genito-Urinary Endocrine Immune System Type Psychological
π Kidney problems π Diabetes π Infectious diseases ________________ π Depression
π Prostate problems π Hypo-thyroid π Immune diseases __________________ π Anxiety
π Urinary problems π Hyper-thyroid π Skin disorders ____________________ π Panic attacks
π Menopause π Pituitary π Arthritis π Bipolar disorder
π Adrenal π Schizophrenia
Hematologic___________ Cancers___ _______________ _______
π Anemia π Lymphoma π Brain π Ovarian π Lung π Stomach π Colon/Rectal
π Leukemia π Sickle cell disease π Breast π Prostate π Liver π Skin π Other ______________
Past Surgical History ________________________________________________________________________________________
_________________________________________________________________________________________
Any difficulty with surgery or anesthesia? _____________________________________________________________________________
Family Medical History (List all conditions: for example - diabetes, high blood pressure, cancer, etc)
___________________________________ ___________________________________ ___________________________________
___________________________________ ___________________________________ ___________________________________
Social History
Tobacco: ( No-never ( Yes-currently ( Yes-in the past
How many packs/day? _________ How many years did you smoke? ______ When did you quit? _____
Alcohol: ( No ( Yes: how many drinks/day? _________ History of Alcohol Abuse: ( No ( Yes: how long have you been sober? _______
Illicit Drug Abuse: ( No ( Yes: please check all that apply ( marijuana ( heroin ( cocaine ( amphetamines ( other: __________________
Have you ever had a problem w/ prescription medications (ie: misuse, abuse, addiction)? ( No ( Yes: which drugs? ______________________
PAIN INFORMATION
IF you have pain please fill out the following, if not skip to following page
Least---------------------------------------------------->Worst
0 1 2 3 4 5 6 7 8 9 10
Please rate your pain by circling the number that best describes your pain at its WORST.
0 1 2 3 4 5 6 7 8 9 10
Please rate your pain by circling the number that best describes your pain at its LEAST.
0 1 2 3 4 5 6 7 8 9 10
Please rate your pain by circling the number that best describes your pain on the AVERAGE.
How did the pain start?
( Suddenly ( Pulling ( Lifting ( Gradually ( Twisting ( Bending ( Hit from behind
( Injured at work ( Fall ( Sports Injury ( Auto accident ( No apparent cause
( Other: ______________________________________________
What activities make the pain worse?
( Nothing ( Sitting for long periods ( Weather ( Driving ( Standing for long periods ( Sleeping
( Work ( Walking ( Exercise
What reduces the pain?
( Nothing ( Lying down ( Medication ( Exercise ( Sleeping ( Massage ( Standing ( Heat
( Sitting ( Ice ( Walking ( Other: _________________
Previous Tests
( MRI Neck / Back / Other Facility _________________ ( Previous Neck / Back Surgery performed by Dr.________________
( CT Scan Neck / Back / Other Facility ______________ ( X-Rays Facility __________________________________________
( Bone Scan Facility _____________________________ ( EMG Facility ___________________________________________
PREVIOUS TREATMENTS
Please indicate all the following measures you have tried
Medicines Tried:
(aspirin (celebrex (norflex (orphenadrine) (nortryptiline
(acetaminophen (cymbalta (lyrica (pregabalin) (elavil (amitriptyline)
(motrin (ibuprofen) (tramadol (ultram) (zanaflex (orphenadrine) (zoloft (sertraline)
(aleve (naproxen) (mobic (meloxicam) (flexeril (cyclobenzaprine) (prozac (fluoxetine)
(advil (ibuprofen) (soma (carisoprodol) (toradol (ketorolac) (vicodin (hydrocodone)
(naprosyn (naproxen)
Physical Therapy for this pain:
(Physical Therapy within the last 6 months at:
(None
(Meske Sports & Physical Therapy (Bosque River Physical Therapy
(Select Physical Therapy (Goodall Witcher Physical Therapy
(Providence Physical Therapy (Scott & White Physical Therapy
(Hillcrest Physical Therapy
(Other: ___________________________________________________________________
Epidural Steroid Injection for this pain:
(Injection within the last 6 months at:
(None
(Advanced Pain Care (Pain Clinic (Dr. Hurley)
(Providence Hospital (Hillcrest Hospital
(Other:____________________________________________________________________
Other Treatments for this pain:
(None
(TENS Unit (Heat (Psychotherapy
(Acupuncture (Ice (Traction
(Chiropractic
(Other_____________________________________________________________________
In the last 6 months, I have seen the following doctors for this pain:
_______________________________________________________________________________
SYSTEM REVIEW
Check those symptoms that you have experienced in the last year.
General Eyes Ears/Nose/Throat Cardiovascular Gastrointestinal
π Fevers π Blurring π Earache π Chest pain π Nausea
π Chills π Double Vision π Ear Discharge π Palpitations π Vomiting
π Sweats π Irritation π Tinnitus π Fainting π Diarrhea
π Anorexia π Discharge π Decreased Hearing π Shortness of breath π Constipation
π Fatigue π Vision Loss π Nasal Congestion π Peripheral edema π Change in bowel habits
π Malaise π Eye pain π Nosebleeds Respiratory π Abdominal pain
π Weight loss π Light Sensitivity π Sore Throat π Cough π Black Stool
π Weight gain π Hoarseness π Pneumonia π Bloody Stool
π Aches π Difficulty swallowing π Excessive Sputum π Jaundice
π Voice Changes π Bloody cough
π Wheezing
Male Female
Genito-Urinary Genito-Urinary Musculoskeletal Skin Neurologic
π Painful urination π Vaginal discharge π Back pain π Arthritis π Rash π Transient paralysis
π Blood in urine π Incontinence π Neck pain π Difficulty walking π Itching π Weakness
π Discharge π Painful urination π Arm pain π Dryness π Tingling
π Urinary Frequency π Blood in urine π Leg pain π Suspicious lesions π Seizures
π Urinary Hesitancy π Urinary Frequency π Joint pain π Hair Changes π Tremors
π Night urination π Absence of menstruation π Joint swelling π Vertigo
π Incontinence π Heavy menstruation π Muscle cramps π Headache
π Genital sores π Abnormal vaginal bleeding π Muscle weakness π Numbness
π Decrease Libido π Pelvic pain π Stiffness π Speech difficulties
Psychiatric Endocrine Heme/Lymphatic Allergic/Immunologic
π Depression π Cold Intolerance π Abnormal bruising π Itching π History of Staph
π Anxiety π Heat Intolerance π Bleeding π Hay fever
π Memory loss π Increased thirst π Enlarged lymph nodes π Persistent Infections
π Suicidal thoughts π Increased appetite π Anemia π HIV Exposure
π Hallucinations π Increased urination π Urinary tract infection
π Paranoia π Weight Change π Skin Infections
WORKER’S COMPENSATION (required)
Is the condition you are being seen for today in any way related to an on-the-job injury? ______________________________________________________
If yes, have you filed a claim with your employer? ____________________________________________________________________________________
Type of Injury _________________________________________________________________________________________________________________
Employer name and phone number _______________________________________________________________________________________________
Has this condition ever been considered a work related injury in the past? _________________________________________________________________
I understand that if at any time my condition is found to be work related, treatment must be authorized by my employer’s Workers Compensation Carrier before any further treatment will be offered. If my Workers Compensation coverage is denied for any reason, or my employer fails to honor its agreement to pay my medical bills, I will be responsible for my medical bills. I understand that Dr. Hamilton has elected to not participate in the Texas State Worker’s Compensation Program.
PATIENT CONSENT AND RELEASE
I give H Bruce Hamilton, MD PA permission to examine and treat my condition. I understand that telephone calls and office visits are recorded. If any insurance claim or Workers Compensation claim is filed, I agree that clinical and all other necessary information concerning my condition and treatment may be released to my insurance company, employer, or Workers Compensation Carrier. I authorize payment to H Bruce Hamilton, MD, PA. I understand that if at any time my condition is found to be work related, treatment must be authorized by my employer’s Workers Compensation Carrier before any further treatment will be offered. I also understand that if my Workers Compensation coverage is denied for any reason, or my employer fails to honor its agreement to pay my medical bills, I will be responsible for my medical bills. In consideration of services rendered, I hereby assign and transfer to H Bruce Hamilton, MD PA all rights, title and interest in the benefits payable for services rendered by all of my insurers and/or employee benefit plans, as well as all claims and/or causes of action (including but not limited to breach of fiduciary duty) that I have now and may have in the future related to the failure or refusal of any such insurer/employee benefit plan to properly pay benefits when due. I hereby authorize and instruct the insurers and/or employee benefit plans to pay directly to H Bruce Hamilton, MD PA all benefits due under the terms of my insurance policy or policies and/or employee benefit plans. I will pay H Bruce Hamilton, MD PA for all charges incurred or for all charges in excess of whatever sums may be paid for my insurers and/or employee benefit plans.
_____________________________________________________ ________________________________________
Signature Date
H. Bruce Hamilton MD, P.A. -- FINANCIAL POLICY
Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. Our relationship is with you, the patient, not your insurance carrier. All charges are the responsibility of the patient whether the insurance carrier pays or not. If the insurance company does not pay your claim in full within 30 days, we ask that you contact the carrier to request prompt payment and to inform our office of their response. We accept payments in the form of MasterCard, Visa, money orders, cash (limited to maximum of $5000) and cashable personal checks.
Co pays: The patient is expected to present an insurance card at each visit to determine any changes in eligibility or copay assignments. All copayments and past due balances are due and payable at the time of service. NSF checks are assessed a $30 processing fee. Small Balance Refunds ( ................
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