Physicians Weight Clinic, Inc.
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- Lesley Sharp
- 5 years ago
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1 Acquaintance Sheet Date: Name: Date of Birth: Sex: M F Age: Address: City, State & Zip: Home Phone: Cell: Work: Please put a check mark next to the phone # that would be best to reach you or leave a message. Referred By: Occupation: Employed By: How did you hear about us?
2 Important Treatment Information Please read and Initial each numbered item below 1. I understand to only take the prescribed dosage of oral medication that I am given and I will not give the medication to another person. 2. I will notify this office of ANY and ALL changes of prescribed and over the counter medications I am taking, including strength and dose. 3. I will update this office whenever I have a new diagnosis or new medical issue I am being treated for by all other medical offices I receive care from. This includes psychiatric or emotional disorders as well as any new medications when prescribed elsewhere. 4. I understand I will receive my weight management participation medical examination at Physicians Weight Clinic, Inc. for the sole purpose of the weight management program. All medical staff s directives and treatments should not be regarded as care from a primary care physician. 5. I understand all injections have inherent risk which may include, but not be limited to, bruising, bleeding, infection, injection site reaction and allergic reaction. 6. Federal regulations require packaging of medication in child resistant containers if children are present to prevent accidental ingestion. PRINT Name: I have read, understood, agreed to and initialed all the items above. Patient s Signature: Date
3 Possible Program Contraindications Please circle your answers to these questions, and then sign below: Are you pregnant, breastfeeding or planning to get pregnant soon? (Appetite suppressant medication should not be taken while pregnant, breastfeeding or attempting to conceive as the risks to the fetus and fertility are unknown, but potentially serious or life threatening. Serious adverse reactions can occur in nursing infants.) Are you currently on: Prozac, Paxil, Zoloft, Celexa, Effexor, Wellbutrin, Elavil, Cymbalta,Trazodone, Buspirone (Buspar), St. John s Wort, or any other type of anti-depressant? Are you currently on any medication for migraines such as; Axert, Amerge, Imitrex, Imigran, or Zomig? Are you currently on Nardil, Parnate, Marplan, or Emsam (MAOI) Have untreated or uncontrolled high blood pressure? History of any heart problem: e.g. By-pass surgery, stent, valve problem? Other Heart disease: Pacemaker, defibrillator, arrhythmia, WPW? History of a Stroke - Cerebrovascular accident (CVA)? History of peripheral arterial/vascular disease (PAD/PVD)? Advanced kidney or liver disease? History of Thyroid disease? Have ever or currently undergoing drug addiction treatment? Are you allergic, or ever had a bad reaction to stimulant drugs? If you answer YES to any of the ABOVE please inform the office Before scheduling your initial appointment. Thank You! Print your name above Patient s signature Date
4 Medical History Questionnaire This medical history and physical exam are for our purposes at Physicians Weight Clinic and in no way replace your care and exams with your health care provider. NAME: DOB: AGE: HT: Please list ALL drug ALLERGIES, including prescription, herbal and over-the-counter medications: Please list ALL medications and dosage you are taking, including prescription, herbal and over-the-counter medications: Please list ALL diet medications you have used: Do you have ANY history of? Heart disease/problems (of any kind) Y or N Alcoholism or Drug Abuse Y or N Irregular Heart beat/palpitations/chest pain Y or N Shortness of breath (without exertion) Y or N Heart murmur or mitral valve prolapse Y or N High Cholesterol Y or N High Blood Pressure Y or N Stroke Y or N Depression, Anxiety, or Panic Disorder Y or N Headaches or Migraines Y or N Anorexia, Bulimia, or other eating disorder Y or N Glaucoma Y or N Sensitivity to Stimulant drugs Y or N Thyroid Problems Y or N Diabetes: I, II or Gestational Y or N Positive TB test/treatment for TB Y or N Seizures or epilepsy Y or N Liver disease, hepatitis, jaundice Y or N Lung disease: COPD, asthma, emphysema Y or N Gallstones Y or N Peripheral Arterial Disease Y or N Scarlet Fever or rheumatic fever Y or N Blood disease: Anemia, blood clots, sickle cell, bleeding problems Y or N Digestive Problems: IBS, chronic constipation, diarrhea, acid reflux, diverticulitis, ulcers Y or N Are you Pregnant or Breastfeeding? Y or N Date of last menstrual period/menopause: What is your current birth control method? Do you have any Family History of: heart disease, high blood pressure, stroke, or diabetes? If yes, please list who and at what age they were diagnosed. Is there any ADDITIONAL INFORMATION regarding your medical history you would like us to know? I declare to the best of my knowledge this information is complete and true. I agree Physicians Weight Clinic providers believing it to be TRUE, shall rely and act upon it in making medical decisions about my weight loss treatment. Patient s signature: Date: Physicians Weight Clinic reviewer signature: Date:
5 HIPAA Notice of Privacy Practices How your HEALTH INFORMATION may be used: TO PROVIDE TREATMENT We will use your Health Information within our office to provide you with the best health care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between physician assistant, nurse practitioner, nurse physician and business office staff. In addition, we may share your health information with referring physicians, clinical and pathology laboratories, pharmacies or other health care personnel providing you treatment. TO CONDUCT HEALTH CARE OPERATIONS Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in the training progress for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities. PATIENT REMINDERS Because we believe regular care is very important to your general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best care modern medicine can provide. They may include letters, telephone reminders, or voice mails regarding labs or future appointments. Please be sure the receptionist has your current contact information to insure accuracy and your privacy. FOR LAW ENFORCEMENT As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above or where Federal, State of Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time. I have read and understand the above information. Signature: Date:
Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
Medical History. Patient Information. Dental History. Your current physical health is: Good Fair Poor
Medical History Your current physical health is: Good Fair Poor Cruse Dental Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,
R. B. KO L A C H A L A M M. D. GENERAL SURGERY
GENERAL SURGERY Patient Information (Please Print and Circle or check the appropriate response) Patient s Name: DOB: _ Address: City: _ Zip: Home Phone: Cell: Work:_ Email Address: Patient s SSN: Male
LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
Welcome and thank you for choosing Jerman Family Dentistry
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Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
Patient s Legal Name: Preferred Name: First Middle Last
Douglas County Dental Clinic Patient Registration Revised August 2016 We REQUIRE A Parent, Guardian, Or Other Legally Responsible Party To Complete & Sign all forms. Please provide a photo ID, Proof of
2017 Medi-Slim Weight Loss Patient Information Form
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MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
Independent Wellness Center 1000 W. Apache Trail, Suite #108, Apache Junction, AZ Phone# Fax #
PATIENT INTAKE Welcome t o Independent Wellness Center. In order to provide you with the best health care and assist you with other details of our clinic, we have provided the following information. We
Social Security Number: Employment Status: Employed Unemployed Address: Student Retired
Please complete all forms fully and to the best of your ability. If something does not apply to you please write N/A in the field. Patient Demographics: Name: Sex: Male Female Address: Apt: City: Marital
Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
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ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
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Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
BETHESDA DENTAL GROUP
PLEASE COMPLETE ALLINFORMATION THAT APPLIES TO YOU - THANK YOU PATIENT LAST NAME: FIRST: INITIAL How did you hear about us? Whom may we thank for your referral? Date of Birth: Single: Married: Divorced:
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Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801
How did you hear of our office? New Patient Registration SECTION 1: PATIENT INFORMATION Patient Name: M / F Date of Birth: Address: City: State: Zip Code: SECTION 2: PARENT / GUARDIAN / INSURANCE Name:
New Patient Registration Form NJR_NP_F100
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Dear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
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PATIENT REGISTRATION FORM
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PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
TRINITY DENTAL CLINIC Medical History Form Date:
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INSURANCE INFORMATION
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NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please
PATIENT INFORMATION (Please Print)
PATIENT INFORMATION (Please Print) Patient Name: Home Phone: Patient Date of Birth: Cell Phone: Patient Social Security #: Sex: Consent to call? Yes No Consent to text? Yes No Address: Work Phone: City:
Virginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
Medications List. Allergies. Drug Name Dosage Directions Reason Taking
Patient Name: DOB: Medications List Allergies Please list any medications you are currently taking Drug Name Dosage Directions Reason Taking Preferred Pharmacy: Date: Location/Number: New Patient Background
TOS Health Questionnaire
Name Referring Physician Main Reason for Medical Evaluation of Injury/Length of symptoms: Is this a work related problem? Y N Are you right or left handed? Occupation What treatment have you received for
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Date of Birth: SSN: Cell Number: Cell Phone Provider: Home Number: Work Number: Home Address: City/State: Zip: Employer: Occupation: E-Mail: Relationship Status: S M W
1419 Salt Springs Road Syracuse, NY (Health Office)
1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) Dear FAMILY NURSE PRACTITIONER Student: Congratulations! As Nurse Manager of the Wellness Center I would like to welcome you
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE
REGISTRATION (please print) PATIENT INFORMATION DATE: NAME SS# ADDRESS CITY STATE ZIP TELEPHONE (home) (business) Cell Email SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE MOTHER'S FIRST NAME
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION
Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW
History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia
History Form Name: Date of Birth: Today's Date: Height: Weight: Date of Injury: Primary Care Physician: Address Who recommended this office? Address CHIEF COMPLAINT Why are you seeing the doctor today?
Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
MICHELE S. GREEN, M.D.
MICHELE S. GREEN, M.D. Name Last First Middle initial Address Number Street Apt# City, State Zip Home Cell Email Please Circle: Preferred Contact Number Home Cell Work Single Married Divorced Widowed Male