Pulmonary Hypertension Center Oklahoma Heart Hospital

Pulmonary Hypertension Center at

Oklahoma Heart Hospital

New Patient History Form

Confidential Record: Information contained here will not be released unless you have authorized us to do so.

Please fill out form the best you can.

Name

Age

DOB

Today's Date

What doctor referred you to our clinic? Dr.

If not referred by a physician, how did you hear about us?

Primary Care Physician and Phone number? Dr.

What are your current symptoms? (Check all that apply)

Shortness of breath

Chest Pain or Tightness

Chest pain

Abdominal swelling or bloating

Racing Heart or Palpitations

Feeling more tired than you should be

Leg Swelling

Lightheaded with activity

Passing out or feeling like you're about to pass out

Do you currently have or have you ever been diagnosed with any of the following medical conditions?

High Blood Pressure (Hypertension)

Scleroderma

Coronary Artery Disease, Heart Attack or Heart Stent

Lupus

Congestive Heart Failure

Rheumatoid Arthritis

Lung Disease (circle) Asthma, COPD, Interstitial Lung

Mixed Connective Tissue Disease

Disease, Pulmonary Fibrosis, Sarcoidosis, Other

Obstructive Sleep Apnea (OSA)

HIV or AIDS

Blood Clot in your leg (Deep vein thrombosis, DVT)

Blood clot in your lung (Pulmonary embolus, PE)

Liver disease or Cirrhosis of the Liver

Sickle Cell Anemia

Hemolytic Anemia

Have you ever taken any of the following medications or drugs?

Aminorex (Menacil or Apiquel)

Fenfluramine (Fen-Phen, Pondimin, Adifax, or Pondirax)

Dexfenfluramine (Redux)

Benfluorex (Mediator)

Medications for Depression or Anxiety

St John's Wort

Tryptophan

Rapeseed Oil

Interferon alpha or beta

Please list medications you are currently taking, including over the counter medicines (or attach a list).

Name, dose, and frequency

1.

7.

2.

8.

3.

9.

4.

10.

5.

11.

6.

12.

OHHP-F581A (N. 11/14)

ist any allergies or adverse reactions to medications

No Allergies

1.

3.

2.

4.

ist any surgeries/procedures and dates

ocial History

Are you: employed retired disabled at-home spouse/parent

What is/was your occupation?

Have you ever used illicit drugs?

Yes No

Have you ever injected drugs?

Yes No

Have you ever smoked cigarettes? Yes No

Have you ever used Methamphetamine(Meth)? Yes No

Have you ever used cocaine?

Yes No

If yes, how many cigarettes/day (on average)?

Do you drink alcohol?

Yes No

For how many years?

How many drinks/week?

Are you still smoking?

Yes No

Hot tub or sauna?

Yes No

Birds in the home?

Yes No

Feather bedding?

Yes No

Mold in the home?

Yes No

Asbestos exposure?

Yes No

Chemical Exposure?

Yes No

Mine worker?

Yes No

amily History

Are you married?

Yes No

Living arrangements?

Is there anyone in your family who has ever been diagnosed with pulmonary hypertension?

Yes No

Please list any known health problems with family members

Mother-

Father-

Siblings-

Children-

Others-

pworth leepiness cale

How likely are you to fall asleep or doze in the circumstances listed below? When rating these situations, give the

highest consideration to recent events. If you have never experienced one of the situations, estimate how you might

have reacted.

No chance light chance oderate chance High Chance

ituation

Chance of Dozing ( )

Sitting and reading

Watching television

Sitting inactive in a public place (ie theater or meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon

Sitting and talking quietly with someone

Sitting quietly after lunch (without alcohol)

In a car, while stopped for a few minutes in traffic

OHHP-F581B (N. 11/14)

Review of ystems

Constitutional Do you often feel tired or worn out? Do you have frequent fevers or chills? Has your weight changed (lost or gained) by

more than 5 pounds in the last year? Do you have night sweats?

yes Have you had a change in your vision recently? Do you have blurry or double vision?

N Do you have:

Dry mouth? Trouble hearing? Frequent or severe nosebleeds? Frequent nasal congestion or stuffiness? Ringing or buzzing in your ears? Sore throat?

Respiratory Are you short of breath with:

Resting or sitting comfortably? Getting ready for your day? (Bathing, Putting on your clothes, preparing a meal) Going up one or two flights of stairs? Walking at your own pace on level ground? Walking briskly, running, or working out? Lying flat? Do you sleep in a recliner or with multiple pillows at night? Are you short of breath with bending over to tie your shoes or to pick something up? Do you have a frequent cough? Do you ever cough up blood?

usculoskeletal Do you have joint pain or stiffness?

If so, where? Do your fingers or toes turn bluish or white when they get cold? (Raynaud's) Do you have muscle weakness?

Do you have significant pain that would prevent you from walking at your own pace for 5-6 minutes?

es No

Cardiovascular Do you have pain, tightness or

pressure in your chest? If yes, is it only with activity? Does your heart ever beat so fast it feels like

it's racing or beating out of your chest? Do you have swelling of your feet or ankles? Do you frequently feel bloated ? Has your waist size increased due to

swelling of your abdomen?

astrointestinal Do you have:

Heartburn or indigestion after meals? Poor appetite? Frequent nausea or vomiting? Pain with swallowing? Sensation of food getting `stuck' in your

throat while swallowing? Constipation? Diarrhea? Blood in your stools?

Central Nervous ystem Do you have frequent or severe headaches? Do you have episodes where you feel

the room is spinning? Have you recently fainted, passed out, or

almost passed out? Do you have numbness or tingling in your

head, arms or legs? Do you have problems with seizures? Do you consider yourself a nervous person? Do you struggle with feeling depressed? Have you lost a desire to do things you

normally enjoy? Do you have panic attacks?

Women nly Do you still have menstrual cycles? Do you take medication or have an internal

device to prevent pregnancy? (Diaphragm, IUD, etc)

Have you had surgery that would prevent pregnancy? (Hysterectomy, tubes tied, etc.)

es No

Form Revision #

Form Changes

OHHP-F581 (N. 11/14) Original

PLEASE PRINT

PATIENT INFORMATION

If this is work-related, stop and notify receptionist.

Date

Referring Physician & Phone Number

Family Physician & Phone Number

OHHP Physician & Phone Number

LEGAL NAME Last

Preferred Name

Suffix

First

Middle

Sex

`M `F

Address

City

Country

Home Telephone

( )

Marital Status:

SS#

S M W D DEP

Race:

` African American

` Asian

` Caucasian

` Hispanic

` Native American

` Pacific Islander ` Other

Ethnicity: ` Hispanic or Latino ` Non-Hispanic or Non-Latino

Religion:

Employer

Address

City

State

Age

Birthdate

?

?

Language: ` English ` Spanish ` Other

State

Zip

/

/

Interpreter needed? ` Yes ` No

Zip

Employment Status: Full-time Full-time student Not employed Military Part-time Part-time student Retired Self-employed

Business Phone & Ext.

( )

Cell Phone

Pager

E-Mail

May we contact you

through email?

Yes

No

NPaetxiet notf'sKiPnri(mNaOrKy)Contact (Other than SpousCeonnottalcivt'isngDOinBthe same reRseidlaetniocnes)hiCpotontPacati'tsenDtOBHome Phone RelationWshoiprktoPhPoantieen&t Ext. Cell Phone

( )

( )

( )

EHmomeregePnhcoyneContact (EMC)

( )

ContacWt'sorDkOPBhone & Ext.Relationship to Paitent Home Phone

( )

( )

CeWlloPrkhoPnheone & Ext. Cell Phone

( )

( )

Spouse/Parent

SPOUSE/PARENT INFORMATION

Spouse or parent information (if child under 18) Relation to Patient

Home Telephone

( )

Cell Phone

Employment Status: Employer

Full-time

Address

Full-time student Not employed Military

SS#

?

?

City

Part-time Birthdate

Part-time student Retired Self-employed

Age

Work Phone & Ext.

( )

State

Zip

INSURANCE INFORMATION (Provide cards to copy) Do you have Health Insurance Coverage? Yes or No (If yes, please complete the primary and secondary info below.)

Primary Insurance

Insurance Type

Insured's Name on Card

I.D. #

` Group

` Individual

Group #

` Cobra

Insured's Birthdate

/

/

Secondary Insurance

Insured's Name on Card

Patient Relation to Insured

` Self ` Spouse ` Child ` Other

I.D. #

Insured's Sex

`M `F

Insured's SS#

?

?

Insurance Type

` Group

` Individual

Group #

` Cobra

Insured's Birthdate

Patient Relation to Insured

Insured's Sex

Insured's SS#

/

/

` Self ` Spouse ` Child ` Other ` M

` F

?

?

OTHER INFORMATION

I authorize the release of medical information required to process all claims on my behalf. I also authorize payment of insurance benefits from those claims be made payable to: OKLAHOMA HEART HOSPITAL PHYSICIANS. I understand I am financially responsible for any charges not covered by my insurance.

Form Revision # OHHP-F67PB (Rev. 2/13) OHHP-F67PB (Rev. 6/17)

Form Changes Revision table added NOK & ER contact

PATIENT OR AUTHORIZED PERSON

DATE

Patient Name:______________________________________ Admission Date:____________________________________ MRN:____________________________________________

CONDITIONS OF ADMISSION

Medical and Surgical Consent: The patient, or his or her representative, hereby acknowledges the patient's need for hospitalization or

treatment because he or she suffers from a condition requiring diagnosis and medical and/or surgical treatment. The undersigned requests and

voluntarily consents to the patient's receipt of the usual Hospital services, as well as the diagnostic laboratory (such as testing of the blood and

other bodily fluids), x-ray procedures, medical and/or surgical treatment, including administration of anesthesia judged to be necessary by the

patient's attending physician, his assistants or other physicians designated by him. The Hospital is authorized to retain, preserve and use for

scientific or teaching purposes, or dispose of at its convenience any specimens or tissue removed from the patient's body during hospitalization

or treatment.

Assignment of Insurance Benefits: I hereby authorize payments from all insurance companies to be made directly to OKLAHOMA HEART

HOSPITAL and/or Oklahoma Heart Hospital Physicians for benefits otherwise payable to me. I understand that I am financially responsible

to the hospital for charges not covered by this assignment. I certify that the above information in support of this claim is true and correct.

Payment Responsibility: The undersigned understands that the patient, or another person who specifically agrees to guarantee payment for the

patient, is responsible for the payment of all charges of the Hospital or Physician relating to services rendered by the Hospital or Physician to the

patient that exceed any third party coverage, including applicable coinsurance payments and deductibles and all amounts for which payment has

been denied by any third party. There are other services that will be billed separately from the hospital bill including services performed by other

physician specialists who perform services for your care and treatment while a patient at Oklahoma Heart Hospital. Amounts due from the

patient to the Hospital prior to execution of this Agreement may, at the sole discretion of the Hospital, be consolidated with, and made a part of,

the amount due hereunder. The patient shall pay all costs of collection in connection with the enforcement of this commitment, including

reasonable attorney's fees and court costs incurred by the Hospital. You authorize personal contact from us or our third party collector, via

telephone or cell phone numbers provided to us, including line voice, text, auto dialed or prerecorded message.

Other Uses of PHI: I understand that in-hospital staff committees may utilize data relating to my condition in the course of studies for the

purpose of advancing medical research or medical education in the interest of reducing morbidity or mortality. I understand that should the

recipients use or publish such information or material that my identity shall be confidential and shall not be revealed under any circumstances.

Provider Based Billing: When seeing an OHH healthcare provider for any type of outpatient services, you will see a change in the way you are

billed. Under "Provider Based" status, OHH is required to bill provider services in two parts. When your medical services are completed,

OHHP will submit a claim for the professional fee and OHH will submit a claim for the facility fee. You will receive two statements/bills for

your services ? one from Oklahoma Heart Hospital and one from Oklahoma Heart Hospital Physicians.

N/A

________ (Initial) I acknowledge receipt of the Provider Based Medicare Outpatient Coinsurance Notice; actual liability will depend on

services furnished.

N/A

Notification of HIV Testing: The undersigned has been notified of the testing of the patient's blood for human immunodeficiency virus (also

known as AIDS) if determined by the patient's attending physician. This is necessary (i) for determining the appropriate treatment and/or

treatment procedures for the patient or (ii) for the protection of the attending physician and/or any employee or agent of the Hospital or the

attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. __________ (Initial)

Facility Directory: Unless I object, I understand that my name, location, general condition, and religious affiliations may be released to the

clergy or to others who ask for me by name. Agree Object (If I object, I understand I cannot receive phone calls, deliveries, etc.)

________ (Initial)

Acknowledgment of Notice of Privacy Practices: I have received/reviewed the "Notice of Privacy Practices" from Oklahoma Heart Hospital.

If I have any questions, I know to contact the Privacy Officer whose information is provided to me in the "Notice of Privacy Practices". I

understand that if I request a copy of this form one will be provided to me by the Registration staff. _________ (Initial)

Disclosure of Physician Interest: The Oklahoma Heart Hospital has financial relationships with a number of Oklahoma physicians, some of

whom have an ownership interest in the Hospital, and some of whom are paid by the Hospital for services they provide. If the physician who

recommended the Hospital to you has a financial interest, and if his or her financial relationship with the Hospital concerns you, you may be

treated at an alternative facility, if there is one available. If you would like to discuss your options for treatment at other facilities, or if you have

any questions about this disclosure, please ask the person providing you with this form for assistance. A list of physician owners has been

provided to me. _________ (Initial)

THE UNDERSIGNED CERTIFIES THAT HE HAS READ THE FOREGOING AND IS THE PATIENT, OR IS DULY AUTHORIZED BY THE PATIENT AS PATIENT'S GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPTS ITS TERMS.

___________________________ Date

Patient, Patient's Agent or Representative

__________________________ Witness

__________________________________________________ Agent or Representative's Relationship to patient

Date & Version # 11/24/2015 Ver 4 02/24/2017 Ver 5

Change Summary Multiple Changes Multiple Changes

OHHP-F437

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