DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)

Size: px

Start display at page:

Download "DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)"

Arabella Sharon Bailey
6 years ago
Views:

1 NASSAU CHEST PHYSICIANS PC MEDICAL QUESTIONNAIRE 1 DATE: PATIENT NAME: DOB: DRUG / MEDICATION ALLERGIES: (include: Type/Reaction) 9/1/2014 PHARMACY NAME PHARMACY PHONE PHARMACY Street Address City State ZIP PHARMACY Phone MAIL ORDER PHARMACY: PHARMACY FAX OTHER INFO: MEDICATIONS - Name Dose Frequency (ex: twice a day) Medical History: Abdominal Aortic Aneurysm (AAA) Emphysema Neurologic Disorder Allergies Eczema Osteoporosis Asthma GERD (Gastric Reflux) Pulmonary Emboli Atrial Fibrillation (A-Fib) Glaucoma Pulmonary Hypertension Arrhythymia Hay Fever Rheumatoid Disorders Blood Transfusions Heart Murmur Sarcoidosis Cancer-TYPE: HIV / AIDS Sleep Apnea Cataracts Hyperlipidemia Stroke Clotting Disorder Hypertension Thyroid Disease Congestive Heart Failure Interstitial Lung Disease Tuberculosis COPD Kidney Disease Ulcers Coronary Artery Disease Liver Disease Deep Vein Thrombosis (DVT) Myocardial Infarction (Heart Attack) Depression Nasal Polyps Diabetes Mellitus (TYPE: ) Nerve / Muscle Disease

2 NASSAU CHEST PHYSICIANS PC MEDICAL QUESTIONNAIRE 2 DATE: PATIENT NAME: DOB: Additional Medical History: 9/1/2014 Surgical History: Pacemaker Insertion Bronchoscopy Coronary Artery Bypass Graft Cardiac Catheterization Additional Surgical History: Family History: Adopted? Yes No Alive-A / Deceased -D Asthma Cancer Diabetes Emphysema Heart Failure Hypertension Other Mother Father Sister 1 Sister 2 Brother 1 Brother 2 Details as Needed:

3 NASSAU CHEST PHYSICIANS PC MEDICAL QUESTIONNAIRE 3 DATE: PATIENT NAME: DOB: 9/1/2014 Implants: (Include Pacemaker/Breast/etc): Social History: Alchohol Use Yes No Drinks/Week: Glasses of wine Cans of beer Shots of liquor Drinks containing 0.5 oz of alcohol Drug Use No Yes- TYPE: Cocaine Heroine Marijuana Oxycodone DESCRIBE: Tobacco Use: Check most appropriate Item: Current Everyday Smoker Former Smoker Never Smoked Current Some Day Smoker Passive Smoker (2 nd hand smoke) Smoker, Current Status Unknown Unknown If Ever Smoked Tobacco Type: Cigarettes Cigars Pipe Electronic Cigarette Smokeless ( Chew / Snuff) Packs / # Day: Years: Other: Quit Date: N/A ***Are you ready to Quit? Yes No

4 NASSAU CHEST PHYSICIANS, PC PATIENT DEMOGRAPHIC FORM Name (Last, First, MI) Patient Information Street Address City State ZIP Home Phone Preferred Work Phone Preferred Cell Phone Preferred ( ) ( ) ( ) SSN Date of Birth Gender Marital Status / / Race Ethnicity Preferred Language Country of Origin Hispanic Non-Hispanic Female Male Single Married Divorced Partner Widowed Other: Employment / Student Information Employer Name City/State/Zip STUDENT STATUS: Full-time Part-Time EMPLOYMENT STATUS Full-time Part-Time Retired Unemployed Emergency Contact Name Relationship to Patient Home Phone Preferred Work Phone Preferred Cell Phone Preferred ( ) ( ) ( ) Referring Doctor Referring Physician Name NOT APPLICABLE Phone ( ) Fax (if known) Physician Address ( ) PCP Info Primary Care Physician Name Physician Address SAME AS ABOVE Phone ( ) Fax (if known) ( ) Primary Insurance Company Name ID Number Group Number Insurance Information Name of Subscriber (if not the patient) Relationship to Insured Subscriber Effective Date SELF Spouse Child Partner Other: Subscriber Social Sec # Gender: Male Date of Birth Subscriber Employer Employer Phone Female Secondary Insurance Company Name Name of Subscriber (if not the patient) ID Number Relationship to Insured Subscriber Group Number Effective Date SELF Spouse Child Partner Other: Subscriber Social Sec # Gender Male Date of Birth Subscriber Employer Employer Phone Female 233 EAST SHORE RD, GREAT NECK, NY * 643 BROADWAY, MASSAPEQUA, NY Revised 9/1/2014

5 NASSAU CHEST PHYSICIANS, PC PATIENT DEMOGRAPHIC FORM PATIENT NAME: DATE OF BIRTH: > Are you currently residing in a skilled nursing OR rehabilitation facility? No Yes* * If YES: Name / Address / Phone of Facility: *** COMMUNICATIONS There may be instances that your healthcare provider may wish to communicate some aspects of your protected health information via electronic means, either to you and/or another healthcare provider that may be consulted regarding your care or treatment. Nassau Chest Physicians has internet security in place, but we cannot guarantee you privacy for e mail communications over the Internet. BY ENTERING MY ADDRESS AND SIGNING BELOW, I understand and accept this risk, and give permission to Nassau Chest Physicians PC to communicate PHI and other information with me electronically. SIGNATURE: Address: I DO NOT GIVE PERMISSION FOR Initials: MEDICARE PATIENTS ONLY MEDICARE SIGNATURE ON FILE (Medicare patients only): I request that payment of authorized Medicare benefits be made to all providers of Nassau chest Physicians PC who treat me during my office visits and / or hospital stay(s) or any services furnished to me by those providers. I authorize the holder of medical and other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Patient Signature AUTHORIZATION TO RELEASE INFORMATION: I agree with and authorize the taking of x-rays/ ultrasonography / photos / video for medical evaluation and documentation. I understand that my identity will be protected. This authorization will remain in force indefinitely or until I revoke it in writing. PATIENT / LEGAL GUARDIAN SIGNATURE DATE Revised 10/31/ EAST SHORE RD, GREAT NECK, NY * 643 BROADWAY, MASSAPEQUA, NY 11758

NASSAU CHEST PHYSICIANS, PC and BEACON ** GREAT NECK, NY / MASSAPEQUA, NY 8.

7 NASSAU CHEST PHYSICIANS, PC and BEACON ** GREAT NECK, NY / MASSAPEQUA, NY Authorization / Acknowledgement of Receipt of Joint Notice of Privacy Practices PATIENT NAME: DOB: Nassau Chest Physicians PC, member of Beacon Interdependent Practice Organization LLC/Beacon IPA LLC/ Beacon Health Partners LLP (Collectively referred to as Beacon ) considers our patients privacy to be of the utmost importance. Please be assured that protected health information (PHI) will always be maintained with the strictest confidentiality. I acknowledge that I may request and be given a copy of this notice as well as our full and complete Notice of Privacy Practices. ********************************************************************************************************************************************************************************************* USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use / disclose your health information to physicians or other healthcare providers / hospitals providing treatment. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment / improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, accreditation, certification, licensing or credentialing activities. To Your Family and Friends: We must disclose your health information to you, the Patient. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. ********************************************************************************************************************************************************************************************* I authorize this information to be disclosed in the following ways: Written/Photocopy/Paper Verbal Fax Other: I authorize the following family / friends to speak on my behalf and obtain my PHI: Contact Person # 1 NAME: Relationship: Home Phone: Cell Phone: Contact Person # 2 NAME: Relationship: Home Phone: Cell Phone: I would like to place the following RESTRICTIONS on disclosure of my private health information: Your Authorization: In addition to using patient health information for treatment, payment or healthcare operations, the patient may give Nassau Chest Physicians PC special written authorization to use health information or to disclose it to others not listed on this form. If you give us such authorization, you may revoke it in writing at any time. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. This authorization is in effect until the time you write to us changing it. I release the individual or organization named in this authorization from legal responsibility or liability for the disclosure of the records as authorized on this form. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original. Signature of Patient (or Patient Representative) Date Printed Name of Patient or Patient Representative Authority of Representative to Act for Patient (Relationship to Patient)

NASSAU CHEST PHYSICIANS, PC PATIENT DEMOGRAPHIC FORM

NASSAU CHEST PHYSICIANS, PC PATIENT DEMOGRAPHIC FORM Name (Last, First, MI) Patient Information Street Address City State ZIP Home Phone Preferred Work Phone Preferred Cell Phone Preferred ( ) ( ) ( )