patient registration - dr. padma horvitdrpadmahorvit.com/documents/new patient forms.pdfpatient...
TRANSCRIPT
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: ------.1 __ -'/ __ _ Marital Status: Single / 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: ----.-! ---.-1.;..' __ _
Insured Social Security #: ___ ..J1 ___ -'1 ___ _ Relationship: SELF I 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 #: ___ ...JI ____ --'/ ____ _ 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 #: __ ---'1---.-1 __ _ 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 bill ing representat ive 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 billing representative to furnish information to my or
my child's insurance company (s) concerning treatment rendered by Dr. Padma 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 (5).
Signature of Patient or Guarantor: ____________ _ Today's date: ----.-! ---.-1 ___ _
Padma K. Horvit, M.D., P.A. Endocrinology
PATIENT QUESTIONAIRRE
Pharmacy name and number:
Do we have your permission to call you at work?
Yes No --
Do you authorize Dr. Horvit or her staff to leave medically related information on your home or work answering machine?
Yes No --
Patient's signature: _______________________ _
Date: -----------
PADMA K. HORVIT, M.D., P.A. ENDOCRINOLOGY
HEALTH HISTORY
Name: ________________________________ _ DOB: / / Sex: M F
Ref~edBy: ____________________________ _
Check all items that apply to you and fill in blanks as needed
Past Medical History:
_ Allergies (other than drugs ), __________ __
_ Anemia or blood problems
Arthritis
Asthma
_ Cancer/Tumor, explain: ______________ _
Colon disease
_ COPD, emphysema, lung disease
_ Diabetes, type __ , how long ___ _
_ Drug or alcohol abuse
_ Epilepsy
Glaucoma
_ Headaches, type __________________ ~
Past Surgical & Hospitalization History:
_ Angioplasty or _ Heart Bypass
_ Appendectomy
_ Back, procedure: __________________ _
_ Breast, R or L, procedure: ______ _
_ Cervical freezing or LEEP
Fracture, ________________________ _
Gallbladder
_ Hernia, R or L, type: ________ _
_ Hearing loss
Heart disease or heart attack
_ Hepatitis ABC or jaundice
_ Hypertension (high blood pressure)
_ Hypothyroid or hyperthyroid
_ Kidney disease or stone
_ Mental illness or depression
_ Pap smear, abnormal
_ Peptic ulcer disease
Stroke
Tuberculosis (TB)
Other: --------------------
_ Hysterectomy (uterus) Ovaries removed
_ Knee, R or L, procedure: ___ _
_ Psychiatric treatment, inpatient or outpatient
_ Tonsillectomy
_ Tubal ligation (Tubes tied)
_ Vasectomy
Other: _____________ _
Other: ----------
",--- -- ------- - --------------------- ------------
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 __ _
Males Only: Date of last: Physical exam __ _
Drug Allergies: _No Known Drug Allergies
Name of Drug
Mammogram ___ _
Prostate exam --- PSA __
Reaction
Current Medications: (prescription, over-the-counter, herbs, vitamins)
Medication StrengthIDose Frequency Medication StrengthIDose Frequency
Social History:
Marital Status: Married Divorced _ Single _Separated Widowed
Occupation: ___________ _ Highest level of education: _____ _
Tobacco: _Cigarettes Smokeless How muchlday: __ _ how long _ quit when __
Alcohol: Number of drinks per day or week _-----------
Caffeine: Number of cups of coffee __ /day, glasses of tea __ ---'/day, sodas __ /day
Do you exercise regularly? _______________________ ~
Family History:
Father Mother Father's father Father's mother Mother's father Mother's mother Brothers
Sisters
Children
Age Living Deceased
Health status or illness Cause of death & illnesses
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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 throat, hoarseness, or difficulty swallowing
Shortness of breath
Chronic cough
Chest pain or irregular heart beat
Abdominal 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
Nervousness
Change in appetite
Difficulty concentrating
Depression
Sleeping too much - average sleep per night: hours
Inability to sleep (Insomnia) - average sleep per night: hours
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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: ____ _
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