PATIENT REGISTRATION

Transcription

1 PATIENT REGISTRATION **Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying** First Name: Last Name: Middle Initial: Address: Apt#: City: State: Zip: Date of Birth: },! Marital Status: Single I Married/ Separated/ Divorced /Widowed Who referred you? Doctor's Name: Phone#: ( ) Social Security Number: ;, Drivers License#: State: Employer/ School: Occupation: Sex: Male or Female Home#:( ) Cell#:( ) Work#:( ) Ext.: Emergency Contact Name: Relationship: Home#:( ) Cell#:( ) Work#:( ) Ext.: ,------= Primary Insurance Name: PPO/HMO/POS/INDEMINTY/other: Insured Name: Date of birth of policy holder: /' J Insured Social Security#:,---~ Relationship: SELF/ HUSBAND/ OTHER: ID/Policy /Cert.#: Group/Account#: Secondary Insurance Name (if any): PPO/HMO/POS/INDEMINTY/other: Insured Name: Date of birth of policy holder: } / Insured Social Security#:,----~ Relationship: SELF/ HUSBAND/ OTHER: ID/Policy/Cert.#: Group/ Account#:,..- RESPONSIBLE PARTY (IF OTHER THAN PATIENT) : Name: Date of birth: } } Relationship: Address: Apt#: City: State: Zip: Social Security#: ~ ) Employer Name: Occupation: Home#:( ) Cell#:( ) Work#:( ) Ext.: MEDICAL CARE: I authorize Dr. Padma Horvit, M.D., P.A. or her designee to provide myself or my child with reasonable and proper medical care according to today's standards. MEDICAL INFORMATION: I authorize Dr. Padma Horvit, M.D., P.A. staff and billing representative to release my information necessary to my or my child's insurance company(s), third party payor so that they may obtain payment for medical services rendered. INSURANCE AUTHORIZATION: I hereby authorize Dr. Padma Horvit, M.D., P.A. staff and billink representative to furnish information to my or my child's insurance company (s) concerning treatment rendered by Dr. Pad ma Horvit M.D., P.A. or her designee. ASSIGNMENT OF BENEFITS: I authorize the insurance company(s) or any third party payor to pay benefits directly to Dr. Padma Horvit, M.D., PA, should they accept assignment for such treatment. I ALSO AGREE THAT I AM FINANCIALY RESPONSIBLE FOR_ ALL CHARGES UNPAID BY MY INSURANCE COMPANY (S). Signature of Patient or Guarantor: Today's date: / }

2 [''. /) \..._~ ~.,/. PADMA K. HORVIT, l\tl.d., P.A. ENDOCRINOLOGY HEAL TH HISTORY Name: DOB: / / Sex: M F Referred By: Check all items that apply to you andfill in blanks as needed. Past Medical History: _Allergies (other than drugs),, Anemia or blood problems Arthritis Asthma Cancerffumor, explain:_ Colon disease COPD, emphysema, tung disease Diabetes, type, how long Drug or alcohol abuse _Epilepsy Glaucoma Headaches, type Hearing loss _ Heart disease or heart attack _ Hepatitis A B C or jaundice _Hypertension (high blood pressure) _Hypothyroid or hyperthyroid _ Kldney disease or stone -'-Mental illness or depression _Pap smear, abnormal _Peptic ulcer disease Stroke _Tuberculosis (TB) Other: ~ Past Surgical & Hospitalization History: _Angioplasty or _Heart Bypass _ Appendectomy Back, procedure: Breas~ R or L, proceclure: Cervical freezing or LEEP Fracture, Gallbladder Hernia, R or L, t'jpe: Hysterectomy (uterus) _Ovaries removed _Knee, R or L, procedure: Psychiatric treatment, inpatient or outpatient _Tonsillectomy _Tubal ligation (Tubes tied) _Vasectomy Other: ~---~~~~-~-~ Other: ~~~---~-~

3 HEALTH HISTORY (cont'd) Females Only: Age at first period: yrs. old Birth control method: Number of: Pregnancies_ Live births Miscarriages Abortions Date of last: Period Pap smear Mammogram ~!ales Only: Date of last Physical exam Prostate ex.am PSA --- Drug Allergies: _No Known Drug Allergies Name ofdrug_ Reaction Current Medications: (prescription, over-the--counter, herbs, vitamins) Medication Strength/Dose Frequency Medication Strength/Dose frequency Sodal History: Marital Status: _Married _Divorced _Single _Separated _. Widowed Occupation:. _Hjg.l;t_~.l~YC::l qf education:----- Tobacco: _Cigarettes Smokeless How much/day: how long_ quit when Alcohol: Number of drinks per day or week Caffeine: Number of cups of coffee /day, glasses of tea../9-ay, sod.as /day Do you exercise regularly? -: Family History:. Living Age Health statu.3 or illness Father Mother Father's fatha' Father's mother Mother'sfather Mother's mother Brothers ~ Cause of death & illnesses Sisters Children I,

4 .~. HEALTH HISTORY (cont'd) -~- LIST OF SYMPTOMS PLEASE CHECK ALL THOSE THAT APPLY Excessive weight gain lb. in months Excessive weight loss lb. in months Excessive sweating, hair change or hot/cold insensitivity Prolonged sore thfoa~ hoarseness, or difficulty swallowing Shortness of breath Chronic cough Chest pain or irregular heart beat Abd~minal pain. nausea, change in bowel habits or control Change in urination frequency, pain upon urinating, incontinence Change in menstrual cycle (Women) or impotence (Men) Change in hearing Change in sense of smell or taste Blurred vision Double vision Excessive tearing or.itching of eyes Generalized weakness or fatigue (all muscles) Specific limb or muscle weakness - specify~ Numbness - specify where: Muscle pain or tenderness-:- specify where: Swelling of the ankles Skin changes - specify: Bruise easily Memory loss Nervousoess Change in appetite Difficulty concentrating Depression Sleeping too much- average sleep per night: hours In.ability to sleep (Insomnia)- average sleep per night: hours

5 LIST OF SYMPTOMS (cont'd) Blackouts (fainting spells) Lightheaded - the feeling of almost passing out Vertigo - the feeling of the room or yourself spinning Headaches None of the above Other - specify: Patient's signature:,,. Date: Physician's signature: Date:

6 Dr. Padma K. Horvit, M.D., P.A. Endocrinology PATIENT QUESTIONAIRRE Local Pharmacy Name: Local Pharmacy Number:!.! Mail Order Pharmacy Name (only): Do we have your permission to call you at work? (PLEASE check ONE)* Yes: * No: * Do you authorize Dr. Horvit or her staff to leave medically related information on your: cell, home, work answering machine? (PLEASE CHECK ONE) * Yes: * No: * Patient's signature: Date:..!.!