First Name: Middle: Last Name: Nick name:

Size: px

Start display at page:

Download "First Name: Middle: Last Name: Nick name:"

Marilynn Richard
5 years ago
Views:

1 First Name: Middle: Last Name: Nick name: Date of Birth: / / Age: Gender: Male /Female /Transgender Status: Single /Married /Divorced /Separated / Widow(er) Ethnicity: Hispanic/Latino Y/N RACE: American Indian/Alaskan Native, Asian, Black, Pacific Islander, White 1st LANGUAGE: if not English Cell Phone ( ) Is Text OK? Y / N Home: ( ) Work: ( ) Mailing Address: City/ State /Zip: Home Address (if di erent): Occupation: Employer / SCHOOL: Emergency Contact : NAME: PHONE: ( ) RELATION: PRIMARY INSURANCE: Company: ID#: Group#: Subscriber (Primary Insured) Name Relationship to patient: Subscriber's DOB: / / Subscriber s Mailing Address (if not patient's) Subscriber's PHONE: Subscriber's Employer: 2nd INSURANCE: Company: ID#: Group#: Subscriber (Primary Insured) Name Relationship to patient: Subscriber's DOB: / / Subscriber s Mailing Address (if not patient's) Subscriber's PHONE: Subscriber's Employer: I authorize my insurance benefits to be paid directly to Little Poudre Family Clinic, LLC (LPFC). I authorize the release of any information required to process my insurance claims. I further understand that I am financially responsible for any balance. If LPFC has an agreement with my health plan or insurer, I understand that I am responsible for paying any co-payment or deductible amount today. After 90 days of nonpayment, delinquent accounts shall bear interest at the legal rate allowed. I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect any outstanding balances on my account. I confirm that I have read, or have had read to me, this form. I have had all questions related to this form answered and understand the above. I have read the HIPPA COMPLIANCE REQUIREMENTS and understand my HIPPA rights. I have the right to request further restrictions as to how my health information may be used or disclosed. I acknowledge and agree that results from any diagnostic test may be sent to the address or on my account. In addition, I authorize the release of any medical information deemed necessary by LPFC or its agents to my insurance carrier or entitlement plan, including Medicare and Medicaid. I acknowledge that I have received, or have been given the chance to review, LPFC s Notice of Privacy Policies and the Patient Bill of Rights and Responsibilities. I recognize the information gathered by LPFC may need to be disclosed to a third party for purposes of administration, treatment, payment, and other health care operations. I consent to such release. I understand that LPFC is not an emergency care facility, nor does it have the comprehensive scope or ability to assess or treat ALL medical conditions. I consent to have a Little Poudre Family Clinic, LLC (LPFC) nurse practitioner examine, diagnose, and treat me. Unless consent is subsequently withdrawn, I further consent to a physical examination and diagnostic testing, as recommended by the nurse practitioner. The above information is accurate to the best of my knowledge. Signature Date / /

2 ALLERGY REACTION Active Medical Conditions: Significant Past Medical History: Other Medical Professional that will remain involved in your care: Past Hospitalizations: Surgeries/procedures: Have you had a Mammogram? When: Results: Have you had a Colonoscopy? When: Results: Have you had a Bone Scan? When: Results: Tell us about your Family s Health History (List Medical Problems that might be genetic) Mother: Father: Siblings: OTHER Tobacco History: Cigarettes: How many years? # packs per day? Are you still smoking? Y / N When Did you quit? Chewing Tobacco: Use of Alcohol: Typical amount per day/week/month: Use of Marijuana: Amount smoked /week, Edibles /week Any other recreational substances?

3 Social History With whom do you live? Significant Other s Name: Diet: How many full meals do you eat in the average day? How much of your diet consists of meals prepared at home vs packaged foods or restaurant meals? % How many servings of fruit do you get in the average day? How many servings of vegetables in the average day? Physical Activity in a typical week: MEDICATIONS (Please list all Medications and supplements that take on a regular basis): Medication Dose Frequency Taken Purpose

4 General : Do you regularly have fever or chills? Have you had unexplained weight changes? Eyes: Do you have blurred or double vision? When did you last see an eye doctor? Head : Do you have frequent headaches or migraines? Breast : Do you have breast lumps, tenderness, swelling, or nipple discharge. Chest: Do you have frequent coughing or shortness of breath? Have you ever worked or lived around dirty or polluted air, smoke, second-hand Smoke, or dust? Does your breathing change with seasons, weather, or air quality? Does your breathing make it difficult to do heavy work? Compared to others your age, do you tire easily? In the past 12 months, how many days of work or school have you missed due to colds, bronchitis, or pneumonia? Heart: Is your blood pressure too high lately? Have you ever had a heart attack? Have you had a Stroke? Do you periodically have awareness of flutter sensations, pounding heart, or irregular heart beats? Do you ever get chest pain? If so how often? What does it feel like (sharp, crushing, dull)? How long does it last? What causes it to come on? What makes it go away? Gastrointestinal: Do you get recurring abdominal pain, nausea, vomiting, diarrhea, or constipation? (specify) Do you sometimes have black stools or blood in your stools? Genitourinary : Do you have a history of kidney stones? Yes or No If so how many times? Do you get urinary tract infections periodically? Do you currently have foul smelling urine? Is there an abnormal color to your urine? Do you have urinary leakage or incontinence? Testicular: Do you have testicular pain, lumps, excessive tenderness, swelling?

5 Prostate: Do you typically wake up 2 or more times per night to urinate? Has your urine stream gotten weaker than when you were younger? Do you sometimes have erectile dysfunction? Skin: Do you have rashes, unusual moles, or other skin concerns? Do you realize that you should wear sunscreen daily to avoid skin cancers? Musculoskeletal: Do you have ongoing or recurring joint pain? Do you have ongoing or recurring back pain? Do you have ongoing muscle problems? Neurologic: Have you ever had a stroke or TIA? Seizures? Do you have weakness, numbness or tingling? Psychiatric : Do you feel like you regularly react poorly to stress? Do you have excessive anxiety? Do you have feelings of depression? Do you tend to obsess about things? Are you able to focus and concentrate well? Is your memory as good as most other people's memory? Endocrine : Do you tend to have excessive thirst? Do you have an abnormal intolerance of excessive heat? or cold? Immunologic: Do you have a history of tuberculosis, hepatitis, or recurrent infections? Hematologic : Do you have a history of anemia? When? Do you bleed or bruise excessively (perhaps without knowing of an injury)?

6 Request for Medical Records On behalf of PATIENT: Date of Birth: / / I hereby request that records be sent from the following medical providers to Little Poudre Family Medical. PROVIDER #1: PHONE: ( ) - FAX: ( ) - PROVIDER #2: PHONE: ( ) - FAX: ( ) - PROVIDER #3: PHONE: ( ) - FAX: ( ) - I authorize the release of all medical records to Little Poudre Family Medical. I specifically authorize the release of sensitive medical records including those pertaining to substance abuse, psychiatric conditions, and diagnoses of communicable diseases. Exclusions: NONE unless listed here:. Electronic format is preferred. Please FAX or mail CD/DVD of records to: Little Poudre Family Medical, 3817 W County Rd 54G, LaPorte, CO Phone: (970) FAX: (970) This authorization ends in one year from the date signed or sooner if revoked in writing. / / Signature Date Signed

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

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