Storage.googleapis.com



New Patient Medical History QuestionnairePlease complete this form to provide information regarding your medical condition. Feel free to ask your primary care physician for assistance. All information will be kept confidential. Please return the completed questionnaire with the following:Current insurance authorization for an initial surgical consultation.Photocopy of the front and back of your insurance card.Name: ___________________________________________________Date of Birth: __________________________ Age: _______________Home Phone: ______________________________________________Cell Phone: _______________________________________________Email Address: _____________________________________________Primary Language: _________________________________________Address: __________________________________________________City/State/Zip: ____________________________________________Social Security Number: _____________________________________Driver’s License Number: __________________ State: ____________Occupation: _______________________________________________Employer’s Name: _________________________________________Employer’s Address: ________________________________________Business Phone: ___________________________________________Marital Status: _____________________________________________Number Dependents: _______________________________________Spouse’s Name: ____________________________________________Spouse’s Employer: ________________________________________Spouse’s Employer Address: __________________________________Spouse’s Business Phone: ___________________________________Emergency Contact (other than above): ____________________________________________________________________________________Relationship: ______________________________________________Phone Number: ___________________________________________Medical Insurance InformationPrimary Insurance Company: _________________________________Policy Holder and DOB: ______________________________________Subscriber Number: ________________________________________Group Number: ____________________________________________Insurance Company Address: _____________________________________________________________________________________________Secondary Insurance Company: ______________________________Policy Holder and DOB:______________________________________Subscriber Number: ________________________________________Group Number: ____________________________________________Insurance Company Address: _____________________________________________________________________________________________Is the reason for this consultation work related? _______________Consent to TreatI authorize the doctor to perform such examinations, treatments, laboratory tests, and to administer such medications as, in his opinion, are necessary or advisable for myself.Patient’s Signature: _________________________________________Date: ____________________________________________________Consent to Treat MinorsThis section is to be completed by the parent or guardian for all patients whom wish to be examined or treated that are under the age of 18. I authorize the doctor to perform such examinations, treatments, laboratory tests, and to administer such medications as, in his opinion, are necessary or advisable for the minor patient: Print patient’s name: ___________________________________________________________________________________________________Patient’s Signature: _________________________________________Date: ____________________________________________________Release of InformationI authorize the release of any medical information necessary to process any claims and request payment of insurance proceeds including any major medical benefits to the undersigned physician or clinic. This will also serve as authorization for this office to obtain insurance information from Medicare or any other insurance company regarding any claims submitted in my behalf. A copy of these signatures are as valid as the original. Patient’s Signature: ________________________________________Insured’s Signature: ________________________________________Date: ________________________________________________Date: _______________________________________________Consent to PaymentI understand that I am responsible for payment of all charges incurred on behalf of myself and my families regardless of insurance benefits.Patient’s Signature: ________________________________________Insured’s Signature: ________________________________________Date: ________________________________________________Date: _______________________________________________If patient is not the responsible party for this bill, please indicate who is responsible:Name: ___________________________________________________Relationship to Patient: _____________________________________Address: _________________________________________________City/State/Zip: _____________________________________________Contact Phone: ____________________________________________Email Address: ____________________________________________Employer: ________________________________________________Occupation: _______________________________________________Employer’s Address: ________________________________________City/State/Zip: _____________________________________________Responsible Party Social Security Number:______________________Responsible Party Date of Birth: ______________________________Consent to Use and Disclose Protected Health InformationHow We May Use and Disclose Your Health InformationYour protected health information will be used by Surgical Consultants of Dallas to disclose to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.The Notice of Privacy PracticesThe physicians are required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in the “Notice of Privacy Policies and Practices” brochure provided to you. Please review it carefully.You May Place Restrictions on the Use or Disclosure of Your Health InformationYou may request a restriction on the use or disclosure of your protected health information. However, Surgical Consultants of Dallas may or may not agree to your request to restrict the use or disclosure of your protected health information. You may be asked to complete an authorization to activate this request. Please consult with a practice representative or the Privacy Officer if you would like additional information or clarification. It is a violation of the federal privacy standards if Surgical Consultants of Dallas agrees and fails to comply with your request. The restrictions requested will not affect use and disclosure of your information before the date of your request. If you still have questions after reviewing the notice of Privacy Brochure, please consult with a practice representative or Shanda Scifres, Office Manager and Privacy Officer at the location and contact information listed on the back of the brochure. You May Revoke This Consent at Any TimeYou may revoke this consent at any time; however, Surgical Consultants of Dallas requires that you must revoke this consent in writing. If you choose to revoke this consent, the revocation will not affect use and disclosure of your information before the date of the request.Changes to Privacy PracticesThe physicians reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Brochure. Surgical Consultants of Dallas will notify you of any changes of privacy practices either by mail, at your next appointment, or any other pre-approved method of request.SignatureI have reviewed this consent form, received the brochure entitled “Notice of Privacy Policies and Practices” and give my permission to Surgical Consultants od Dallas to disclose my health information in accordance with this consent and the notice provided.Patient Name (Print):__________________ _______________________Patient Representative (Print): _________________________________________Signature of Patient or Representative: __________________________________________Date:_________________________________________SurgeonChristopher Bell, MDJeff Henke, MDSue Jiang, MDB. Ward Lane, MDMichael Sutker, MDReferring ProvidersNames of the doctors who referred you, your primary care doctor, and any other doctor from whom you are receiving careDoctor who referred you: ________________________Referring Doctor Phone Number: __________________Referring Doctor Fax Number: ____________________Primary care physician: __________________________Primary Care Phone number: _____________________Primary Care Fax Number: _______________________Additional physician: ____________________________Specialty: _____________________________________Phone number: ________________________________Additional physician: ____________________________Specialty: _____________________________________Phone number: ________________________________How did you find this practice?Referred by a friend/relativeReferred by a physician or other providerReferred by my insuranceWebsite: __________________________Found you on TV, radio, magazineReason for visit:Past Medical HistoryPlease check any illnesses you have had in the past.General Medical ProblemsObesity-Related ProblemsSeasonal allergies (hay fever)Hypertension (high blood pressure)AnemiaVaricose veins/venous stasis diseaseAnxietyDiabetes (high blood sugar)ArthritisDyslipidemia (high cholesterol)Bleeding disordersPolycystic ovarian syndromeBlood disorderGoutBlood transfusionOsteoarthritis (painful joints)Cancer (list type)Intertrigo (yeast infection in skin folds)Clotting disorderObstructive sleep apnea (stop breath at night)Chronic bronchitis, emphysema, COPDPickwickian syndrome (low blood oxygen)Congestive Heart Failure (CHF)AsthmaGlaucomaGastroesophageal reflux (heartburn, GERD)Heart diseaseFatty liver diseaseHepatitisUrinary stress incontinence (leak urine)HIV/AIDSIntracranial hypertensionIntestinal diseaseMigrainesKidney diseaseDepressionLiver diseaseBlood clots in legs or lungsMyocardial infarction (heart attack)Gallstones or gallbladder diseaseNerve/muscle diseaseOsteoporosisSeizuresSinus disorderSkin diseaseStrokeSubstance abuseThyroid disease UlcersHigh Cholesterol Other (please list): Past Surgical HistoryPlease check any operations you have had.ProcedureYear PerformedAppendectomyBreast surgeryCoronary artery bypass surgeryCholecystectomy (gallbladder removal)Colon surgeryCosmetic surgeryCaesarean section (C-section)Eye surgeryFracture surgery Please specify location: ________________________________________Hernia repair Please specify location: ________________________________________Hysterectomy (uterus removal)Joint replacementPlease specify location: ________________________________________Prostate surgerySmall intestine surgeryTubal ligationValve replacementVasectomyOther (please list):HospitalizationsHave you ever been hospitalized? If YES, please list the date(s) and reasons.MedicationsMedicationDoseHow OftenReasonPrescriberConsent for Medication HistoryI authorize the doctor to access my medication history via an online portal from participating pharmacies..Patient’s Signature: _________________________________________Date: ___________________________________________________ PharmacyPharmacy Name: _________________________________ Pharmacy Number: __________________________________________AllergiesHave you ever had a reaction to any of the following?Latex Yes ________________No ______________IodineYes ________________No ______________IV Contrast Yes ________________No ______________Are you allergic to any medications? If so, list the medication and the reaction that you had. Examples of reactions include anaphylaxis/shock, rash, itching, nausea/vomiting, and shortness of breath. MedicationReactionSocial HistoryDo you live alone? Yes ________________No ______________Do you have difficulty shopping or carry home a 10 pound bag? Yes _______________No ______________Do you have difficulty dressing yourself? Yes _______________No ______________Are you receiving any special help at home? Yes _______________No ______________Have you had 3 or more falls in the past year? Yes ________________No ______________Do you drink alcohol? Yes ____No ____Are you a smoker (circle one):If yes, what is your average number of:Current Former Never Passive_____ glasses of wine/weekHow many packs per day do you smoke? ________________ cans of beer/weekHow many years have you smoked? ____________________ shots of liquor/weekDo you use drugs recreationally?Yes ____No ____If yes, which drugs: _____________________________Family HistoryLivingDeceased AlcoholismAlzheimer’s ArthritisBleeding DisorderBreast cancerCancerColon CancerDepressionDiabetesDrug abuseHeart DiseaseHyperlipidemiaHypertensionKidney DiseaseLiver disease Mental illnessOsteoporosisStrokeThyroid DiseaseTuberculosisVision LossMotherFatherSisterBrotherSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherCousinOtherFamily history of cancer (please specify): Other family medical problems:Review of SystemsHave you experienced any of the following symptoms in the past 3 months?SymptomCommentGENERALYESNOFeversYESNOChillsYESNOWeight lossYESNOMalaise or fatigueYESNOSweatingYESNOWeaknessYESNOPolydipsia (always thirsty)SKINYESNORashYESNOItchingHEAD, EYES, EARS, NOSE, THROATYESNOHeadachesYESNOHearing lossYESNOTinnitus (ringing in the ears)YESNOEar painYESNOEar dischargeYESNONosebleedsYESNONasal congestionYESNOStridor (groan when you breathe)YESNOSore throatYESNOBlurred visionYESNODouble visionYESNOIrritation with lights (photophobia)YESNOEye painYESNOEye dischargeYESNOEye rednessCARDIOVASCULARYESNOChest painYESNOPalpitations (fluttering in the chest)YESNOOrthopnea (difficulty breathing while flat in bed)YESNOClaudication (pain in legs with exercise)YESNOLeg/ankle swellingYESNODifficulty breathing during sleepLUNGSYESNOCoughYESNOHemoptysis (coughing up blood)YESNOShortness of breathYESNOWheezingABDOMENYESNOHeartburnYESNONauseaYESNOVomitingYESNOAbdominal painYESNODiarrhea YESNOConstipationYESNOBright red blood in stoolYESNOMelena (dark, tar-like stools from old blood)SymptomCommentURINARYYESNODysuria (burning during urination)YESNOUrgency (need to urinate quickly)YESNOFrequency (need to urinate often)YESNOHematuria (blood in the urine)YESNOFlank painMUSCULOSKELETALYESNOMyalgias (crampy muscle pain)YESNONeck painYESNOBack painYESNOJoint painYESNOFallsBLOODYESNOEasy bruising or bleedingYESNOSeasonal allergiesYESNOBlood clotsNEUROLOGICYESNODizzinessYESNOTinglingYESNOTremorYESNOSensory changeYESNOSpeech changeYESNOFocal weaknessYESNOSeizures YESNOLoss of consciousnessPSYCHIATRICYESNODepressionYESNOSuicidal ideasYESNOSubstance abuseYESNOHallucinationsYESNONervous/anxiousYESNOInsomniaYESNOMemory loss ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download