Coastal Cardiology, PA Patient Registration

Transcription

1 Cardiologist: Patient Information Coastal Cardiology, PA Patient Registration Primary Physician: Account # SS# Gender: Age: D.O.B: First Name: Middle Init: Last Name: Marital Status: Check the box of the Primary Phone Number Address: Home Phone: City, State & Zip: Work Phone: Cell Phone: Race/Ethnicity: Black Hispanic White Other: Primary Language: Employer: Responsible Party Relationship to Patient: Self (information same as above) Date of Birth: First Name: Initial: Last Name: Address: City, State & Zip: Social Security # Insurance Information Home Phone: Work Phone: Cell Phone: Primary Insurance Subscriber: DOB: Address: Policy ID: Group: City, State & Zip: Plan Phone #: Patient Relationship to Subscriber: Secondary Insurance Subscriber: DOB: Address: Policy ID: Group: City, State & Zip Plan Phone # Patient Relationship to Subscriber: Parent/Spouse/Legal Guardian: Emergency Contact: Address (if different) Address (if different): Relationship to Patient: Relationship to Patient: Home Phone: Other Phone: Home Phone: Other Phone: Medical Authorizations & Release of Information I hereby authorize Coastal Cardiology, PA to furnish the insured s insurance company all information which said insurance may request my present illness or injury. I hereby assign to the doctors all money which I am entitled for medical and/or surgical expenses relative to the services performed. I understand that I am financially responsible to said doctors for all charges. I hereby authorize Coastal Cardiology, PA to provide such medical services including surgery. If necessary, either regular or emergency, as may be determined to be in the best interest of the patient listed above. This authorization shall continue to be in full force and effect until revoked in writing by me. Signature ***OVER*** Date

2 Coastal Cardiology, PA Patient Registration Payment of Services, Insurance Benefits, Authorization to Release/Obtain Information I hereby authorize Coastal Cardiology, PA to obtain any medical records concerning my care from any physician, hospital or other health care professional that has provided medical care to me in the past.. I also authorize the Practice to release any medical records concerning my care to any physician, hospital or other health care professional providing care to me. Additionally, I authorize the Practice to release any medical records concerning my care to my medical insurance company (i.e. Medicare, Medicaid, and insurance company, third party administrator, or managed care company) except as specifically provided below. I am aware that the records may contain information relating to psychiatric or psychological testing, physical abuse and/or alcohol abuse and/or HIV test results if any.. I realize that I am responsible for payment of all medical service rendered to me and/or my dependents, regardless of the decision regarding reimbursement made by my insurance carrier. If I am not eligible or services rendered are not covered benefits under the terms of my employers Medical and Hospital Subscriber Agreement, I am liable for all charges for services rendered. All appointments are confirmed by an automated system and we encourage you to listen to the entire message. 24 hour notice of cancellation is required. Failure to provide adequate notice may result in a $50 No Show fee that must be paid prior to rescheduling.. Print Name: Signature: Date: Authorization to Release Medical Information to Individuals/Family Members In accordance with Federal government privacy rules implemented through the Healthcare portability act of 1996 (HIPAA), In order for your physician or staff of the Practice to discuss your condition with the members of your family or other individuals (this is someone other than yourself or your doctors) that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to sign your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived. I authorize the Practice to release verbally and/or photo copies of any or all medical and billing information, pertaining to my medical care, to the following family members or individual below. I understand this information may only be released to the individual after proper identification has been presented to the business office. The authorized person may be requested to obtain this information by appearing in person at the business office. I do not authorize the Practice to release any printed or verbal information concerning my medical care to any individual. I authorize the Practice to release verbally and/or photocopies of any of all information concerning my medical care (appointments, prescriptions, etc) to the following individuals. I authorize the Practice to view my prescription history from external sources (other doctors, pharmacies, etc). Print Name Relationship DOB Contact # Print Name Relationship DOB Contact # Patient Signature: Date: Street Address required (if P.O. Box was given on front): Patient Address: City Zip

3 Coastal Cardiology Medical History Name Date DOB Age Referring Physician Reason for Visit Height Weight P R B/P Have you ever had any of the following? Cancer Yes No Heart problems Yes No Weight loss Yes No Speech/Hearing problems Yes No Anemia Yes No Seizures Yes No Infectious Diseases Yes No Arthritis Yes No Kidney problems Yes No Are you pregnant? Yes No Other problems? Yes No Stroke Yes No Eye disease Yes No Nervous Disorder Yes No Asthma/Emphysema Yes No Tuberculosis Yes No Night Sweats Yes No Coughing blood Yes No Difficulty swallowing Yes No Foot or leg ulcers Yes No Poor circulation Yes No Bleeding Problems Yes No Do you have any of the following? Recent weight loss Yes No Chills Yes No Night Sweats Yes No Generalized weakness Yes No Blurry vision Yes No Double vision Yes No Hearing loss Yes No Vertigo Yes No Lightheadedness Yes No Dizziness Yes No Nose bleeds Yes No Sore throat Yes No Hoarse voice Yes No Chest pressure or pain Yes No Skipping heart Yes No Shortness of breath Yes No Short of breath lying flat Yes No Wake up breathless Yes No Swelling of ankles Yes No Leg pain with walking Yes No Wheezing Yes No Cough Yes No Bloody cough Yes No Constipation Yes No Diarrhea Yes No Black/tarry stools Yes No Bloody stools Yes No Painful urination Yes No Incontinence Yes No Bloody urine Yes No Rashes Yes No Itches Yes No Passing out Yes No One sided weakness Yes No Numbness Yes No Tingling Yes No Excessive urination Yes No Excessive thirst Yes No

4 Social History Do you smoke? Yes No Former If Yes, how much? When did you quit? Do you use any illicit drugs? No Yes Occasionally Do you drink alcohol? No Rarely Socially Quit Frequently, drinks a day Do you drink coffee? No Yes cups per day Do you drink tea? No Yes cups per day What type of work do you do? Interests: Do you use any aids such as a walker, cane, wheelchair, hearing aid, etc.? Do you have any language or learning barriers we need to know about? Marital status: Married Single Widow Divorced In a relationship Children: none son(s) daughter(s) Ages: Exercise: None Regular Occasionally 3x a week or more Type of exercise: Describe your daily eating habits: Please mark all that apply. Family History There is no family history of heart disease or vascular disease. Father: Alive Deceased Age deceased: Mother: Alive Deceased Age deceased:

5 Brother: Alive Deceased Age deceased: Sister: Alive Deceased Age deceased: If you have chest pain please answer the following: Character: Sharp Dull Burning Tightening Other Duration: less than 10 seconds 10 seconds to 1 minute 1 minute to 15 minutes 15 minutes to 60 minutes greater than 60 minutes Provoked by: eating large meals exertion stress or anxiety lying flat pressing on the chest wall other Relieved by: rest walking around taking nitroglycerin eating taking antacids rubbing on chest wall burping other Associated symptoms: (things that occur at the same time you experience chest pain) shortness of breath palpitations sweatiness nausea burping weakness passing out jaw pain arm pain Risk factors: Circle all that apply Diabetes Elevated Cholesterol High Blood Pressure Family History of Heart Disease Miscellaneous Have you seen a cardiologist previously? yes no Have you ever had heart surgery? yes no Have you ever had a heart catheterization? yes no Have you ever been told you have a heart murmur? yes no

6 Current Medications Name Strength Times per Day Please list all known medication allergies: