Midwestern University Clinic Patient Registration Form Please Print

Transcription

1 Midwestern University Clinic Patient Registration Form Please Print FOR OFFICE USE ONLY Pt Acct # Bill to Acct # Please check one: NEW PATIENT PATIENT UPDATE PATIENT INFORMATION Patient Name: (Last) (First) (MI) Gender: M F Date of Birth: / / Marital Status: M D S W Address: City, State, Zip: Please check the box next to the best phone # to reach you during the day Home phone #: Cell phone #: Work phone #: Employer Name: Address: Driver s License #: address: PARENT/GUARDIAN INFORMATION (If Patient is a minor) Name: (Last) (First) (MI) Gender: (Circle) M F Date of Birth: / / Relationship to Patient: Address: City, State, Zip: Please check the box next to the best phone # to reach you during the day Home phone #: Cell phone #: Work phone #: Employer Name: Address: address: Emergency Contact: Phone: How did you hear about us? Work Phone: Relationship: Referred by: The Federal Government requires we obtain the following information for reporting purposes only. People will not be identified by the following information. 1. What is your RACE? A. White B. Asian C. African American D. American Indian/Alaskan Native E. Native Hawaiian F. Pacific Islander G. More than one race 2. What is your ETHNICITY? A. Hispanic/Latino B. Non-Hispanic/Non Latino 3. What is your primary language? A. English B. Spanish C. American Sign Language D. Other INSURANCE INFORMATION Please provide insurance card(s) Primary Insurance Insurance Company: ID #: Group #: Customer Service #: Secondary Insurance Insurance Company: ID #: Group #: Customer Service #: Effective Date: Co-pay: Effective Date: Co-pay: Policy Holder: Policy Holder: Policy Holder DOB : Gender: M F Policy Holder DOB: Relationship to Patient: Policy Holder Employer: Relationship to Patient: Policy Holder Employer: Gender: M F SIGNED DATE

2 Midwestern University Multispecialty Clinic New Patient Questionnaire Patient Name Date DOB MEDICAL HISTORY Have you (patient) ever had or been diagnosed with any of the following? Please circle all that apply Birth defects or Genetic disorder: Gastrointestinal(Stomach/Intestine/Digestion) Neurologic (Brain & Nerves) Cerebral palsy, Down s syndrome, deformed Acid reflux, GERD or Ulcers Brain tumor kidney, Ehlers-Danlos syndrome, Heart defect, Marfan syndrome, Other: General: Bowel obstruction Dementia or Alzheimer s disease Feet, legs or hands swelling (edema) Diverticulitis or Diverticulosis Frequent fainting Chronic fatigue syndrome Colon polyps Guillain-Barre syndrome Insomnia Liver cirrhosis or Hepatitis-A B C alcohol Migraines or daily headaches Motor vehicle accidents Pancreatitis Multiple sclerosis Vitamin deficiency Genitourinary (Urine & Sexual) Myasthenia gravis Head/Eyes/Ears/Nose/Throat Kidney stones Nerve damage (neuropathy) Allergies (environmental) Kidney dysfunction, failure or dialysis Paralysis (Bell s Palsy, polio, stroke) Deafness or hearing loss (with ringing?) Polycystic kidneys Parkinson s disease Eye disorders: cataracts, glaucoma, macular Prostrate problem (enlarged, inflamed) Seizures or epilepsy degeneration Sjogren s Syndrome Erectile dysfunction Spinal cord injury Pulmonary ( breathing): Urinary leaking Stroke (CVA) or mini stroke (TIA) Asthma Menstrual (female disorders), endometriosis, Endocrine (Metabolism & Hormones) fibroids, infertility, 3 or more miscarriages, polycystic ovaries COPD/chronic bronchitis/emphysema/ Musculoskeletal (Muscles/Bones/Joints) Cushing s syndrome or Addison s disease pulmonary fibrosis Pulmonary edema Broken bones Diabetes Sleep apnea Carpal tunnel syndrome Thyroid problems: too high or fast, too low or slow, too big (goiter), nodules (bumps), Grave s or Hashimoto s Cardiovascular (heart, arteries, veins) Gout Infection History: Aneurism of artery Paget s disease Measles, Rubella (German Measles), Mumps, Chicken Pox, Meningitis, Polio, Scarlet Fever, Cold Sores, Heart infection, Hepatitis, HIV, AIDS, Chlamydia, Gonorrhea, Pelvic Inflammatory Disease (PID), Herpes, Trichomonas, Syphilis, Tuberculosis, Lyme Disease Bleeding or blood clotting disorder (DVT, PE) Temporomandibular Joint Syndrome (TMJ) Pneumonia more than 3 times Chronic Anemia Thin bones (osteopenia, osteoporosis) Strep throat more than 5 times Sickle cell anemia Chronic Pain Kidney or urine infection more than 5 times High blood pressure Arthritis Other: High Cholesterol Fibromyalgia Heart Attack Lupus Heart disease (atrial fibrillation, failure, Cancer murmur, valve) Mood Problems: Leukemia or lymphoma Depression, anxiety, panic attacks, bipolar (manic depression), obsessive compulsive disorder (OCD) Melanoma Skin: Eczema, Psoriasis, Rosacea

3 MEDICATIONS Please list all medication, vitamins and herbal supplements you take, including doses and frequency. Also include medicines only taken as needed. ALLERGIES Please list any medications to which you are allergic or have side effects: Medication Reaction

4 Midwestern University Multispecialty Clinic New Patient Questionnaire Patient Name Date DOB Do you have any non-medication allergies? (insect stings, foods, pets, latex, etc)? Please list: Surgical History What surgeries have you had? Any serious injuries? Please circle all that apply, and provide year of occurrence. Surgery Year Surgery Year Head/Eyes/Ears/Nose/Throat: Gastrointestinal (Stomach/Intestine) & Abdomen: Brain surgery Appendix removed Ear tubes, placed, removed Colon or intestinal surgery Eye surgery Gallbladder removed Sinus surgery Hemorrhoids removed Thyroid surgery Hernia repair Tonsils or adenoids removed Weight loss surgery Cardiovascular (Heart, Arteries, Veins): Genitourinary (Urine & Sex Organs): Artery surgery Bladder surgery Dialysis shunt or vein port places and/or removed Cesarean surgery Heart surgery Circumcision as an adult Pacemaker insertion or removal Dilation & curettage of uterus (D & C) Varicose vein surgery Kidney surgery Pulmonary (Breathing): Prostate surgery Chest surgery Tubes tied Lung surgery Uterus surgery Breast: Vasectomy (male sterilization) Breast reduction or enlargement Other & Injuries: Breast lump removed Major motor vehicle accident Breast removed Biopsy: What site? Musculoskeletal (Muscles/Bones/Joints): Blood transfusions: Why? Broken bone surgical repair Cosmetic surgery: What kind? Foot surgery Infection surgically removed Hand surgery Organ transplant: which organ? Joint surgery Radiation for cancer Spine surgery SOCIAL HISTORY Do you smoke? Y N Did you ever? Y N Age when started Age when quit Packs/cigars/pipes per day Would you like to quit? Y N Do you use chewing tobacco? Y N Did you ever? Y N Age when started Age when quit Cans per day Would you like to quit? Y N Do you drink alcohol? Y N Did you ever? Y N Age when started Age when quit Days per week? Drinks per day? Would you like to quit? Y N Have you used any kinds of drugs? Y N Did you ever? Y N What have you tried? Ever used any kind of IV drug? Y N Date of last use Have you ever considered cutting down drinking? Y N Has anyone ever suggested you cut down or stop drinking or using? Y NN Has drinking alcohol or using any substance gotten you into legal trouble? Y N Have you been through rehab? Y N Marital Status Single Committed/Engaged Married Separated Divorced Widowed Living with Spouse/significant other children mother father brothers sisters Friends/roommates How many children do you have? Do you have any pets? What kind how many? Activity & Lifestyle Occupation Does your job require you to: Carry Walk Run Stand Lift Climb Sit How many times per week do you exercise? Hobbies, activities & interests Do you work with animals? What kind?

5 Midwestern University Multispecialty Clinic New Patient Questionnaire Patient Date Name DOB FAMILY HISTORY Please list health problems of your family members. Health Problem Mother Father Brother(B) or Sister (S) Allergies (specify-seasonal, food, medicine?) Alzheimer s, Dementia, Parkinson s Arthritis Asthma Birth Defects (what kind?) Bleeding or Clotting Disorder Cancer (what kind?) Diabetes (type 1 or 2) Epilepsy or Seizures Eye Problems: Glaucoma, Macular Degeneration, Cataracts, Retina Problems Gout Heart Attack or Bypass Surgery Other Heart Disease High Blood Pressure High Cholesterol Immune Problems (lupus, UC, RA, etc?) Kidney Disease Lung Disease Mental Illness or Mood Disorder Migraines Osteopenia or Osteoporosis Skin Disorders Stomach or Intestinal Problems (what kind?) Stroke (CVA) or mini stroke (TIA) Substance Abuse (alcohol/drugs) Thyroid Disorder Tuberculosis Other Other Son (S) or Daughter (D) Grandparent

6 Midwestern University Multispecialty Clinic New Patient Questionnaire Patient Name Date DOB REVIEW OF SYSTEMS: ARE YOU CURRENTLY HAVING ANY PROBLEMS RELALTINS TO THE FOLLOWING AREAS? General: NO CONCERNS fatigue weakness weight changes loss of appetite feeling ill difficulty sleeping Other/Explain: Head/Eyes/Ears/Nose/Throat: NO CONCERNS headache hearing loss sore throat ear pain blurry vision sinus problems swollen glands Other/explain Pulmonary (Breathing): NO CONCERNS shortness of breath chronic cough asthma attack Other/explain Cardiovascular (Heart, Arteries, Veins): NO CONCERNS cold feet calf cramping with exercise calf cramping at rest varicose veins leg swelling leg sores Other/explain Gastrointestinal (Stomach/Intestine/Digestion): NO CONCERNS nausea vomiting constipation diarrhea abdominal pain heartburn blood in stool Other/explain Genitourinary (Urine/Sexual/Reproductive): NO CONCERNS bladder infections frequent urination infertility decreased sex drive menstrual problems Other/explain Musculoskeletal (Muscles/Bones/Joints): NO CONCERNS low back pain hip pain knee pain ankle pain foot pain shoulder pain neck pain elbow pain wrist pain achey joints morning foot pain joint stiffness Other/explain Neurologic (Brain & Nerves): NO CONCERNS numbness in feet tingling burning pain shooting pain dizziness loss of sensation Other/explain Dermatologic (Skin): NO CONERNS dry skin itchy skin open wounds rash strange mole thick scarring after surgery thick nails ingrown nails discolored nails Other/explain Endocrine (Metabolism & Hormones): NO CONCERNS increased thirst increased hunger cold or heat intolerance menopause Other/explain Psychology (Mood, Mental): NO CONCERNS mood changes thoughts of suicide Other/explain

7 MIDWESTERN UNIVERSITY MULTISPECIALTY CLINIC Patient Name: Date: Patient Date of Birth: Pain Scale Please identify your level of pain on the scale provided below. Please describe your pain or condition as it is today: (circle) Aching Burning Squeezing Stabbing Pinching Throbbing Annoying Pressure Constant Intermittent Radiates Numbness Tingling Stiffness Pain Body Map Please indicate the location of any and all current pain and/or irritation on the body diagrams below

8 Midwestern University Multispecialty Clinic New Patient Questionnaire Patient Name Date DOB Living Will Do you have an Advance Directive (Living Will)? If so, does this office have a copy? If not, would you like information about Advance Directives? Daily Living Do you feel safe at home? Y N Are you able to do your own bathing and dressing? Y N Do you use devices such as a walker, cane, wheelchair, oxygen? Y N Do you require assistance to perform other household functions? Y N Do you take care of another adult in your or their home? Y N Do you now, or have you ever seen any specialists? Y N Nutrition Do you follow any particular diet? Caffeine (coffee, tea, soda): If soda, reg/diet? How many ounces per cup? Per day? Military Service None Currently Active Duty Reserve/Guard TYPE OF SPECIALIST CITY DOCTOR S NAME When was your last: Sleep Patterns Physical Hours nightly: Good Moderate Poor EKG Chest Xray Have you ever had any form of manipulative treatment? Bone Scan (DEXA) Osteopathic Y N Chiropractic Y N Other? Lab work Colonoscopy Mammogram Pap Smear Women Only Abdominal Aortic Aneurysm Ultrasound Eye Exam What age did you start menstruating? Dental Exam First day of last menstrual period? Immunizations Tetanus Pneumonia vaccine Prevnar 13 Pneumovax 23 Influenza (Flu) Zostavax (Shingles) Are cycles regular? Y N Length of cycle? Length of flow? Do you have heavy cramping? Y N Heavy Flow? Y N Number of pregnancies Live births Miscarriages Terminations Stillborn Birth Control Method Age of Menopause By giving us as much detail as possible, you are helping us to give you the best possible care. Thank you for your patience.

9 MIDWESTERN UNIVERSITY MULTISPECIALTY CLINIC 3450 Lacey Rd. Chicago, IL PATIENT AUTHORIZATION, ASSIGNMENT, AND ACKNOWLEDGEMENT Patient s Name: Patient s Account Number: Date of Service: 1. PRIVACY NOTICE: (Initial) Midwestern University Clinic s Notice of Privacy Practices provides information about how Midwestern University Clinic may use and disclose my protected health information. I was given and had an opportunity to read Midwestern University Clinic s Notice of Privacy Practices and authorize all practices described in the Notice. 2. AUTHORIZATION TO RELEASE INFORMATION: (Initial) I authorize Midwestern University Clinic to furnish requested information from my medical record to: (1) any insurance company, third-party payor, governmental agency, or workers compensation carrier for the purpose of obtaining payment, and (2) any representatives of local, state, or federal agencies in accordance with law. Such information may include information concerning communicable diseases. I authorize the release of information from or the review of my medical record for the purpose of conducting any medical audits, utilization reviews, or quality assurance reviews. I further authorize Midwestern University Clinic to release information from or copies of my medical record to my referring physician or to any other health care facility or provider to which I may be transferred or referred. 3. ASSIGNMENT OF INSURANCE BENEFITS: (Initial) In consideration of services rendered, I hereby transfer and assign to Midwestern University Clinic and to the licensed physicians, groups, or individuals who perform services for my care and treatment at Midwestern University Clinic, all of my right, title, and interest in any payment for services described herein as provided in any health insurance or similar policy or employee benefit plan. I understand that I am responsible for providing to Midwestern University Clinic all insurance information at the time of admission to allow for verification. I hereby certify that the insurance information that I have provided Midwestern University Clinic is true and accurate as of the date of service and that I am responsible for keeping it updated at all times. I understand that regardless of my assignment of insurance benefits, I remain personally responsible for the total charges of the services rendered. 4. MEDICARE/IDHFSASSIGNMENT OF BENEFITS: (Initial) I certify that the information I provided in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the release of information concerning me and any information needed for filing a Medicare claim to the Centers for Medicare and Medicaid Services or its Medicare Administrative Contractors. I request that payment of authorized benefits be made on my behalf and I assign my benefits payable to the physician or organization submitting a claim to Medicare for me. I understand that IDHFS recipients are responsible for payment of any medical care or service rendered that is a non covered benefit of the IDHFS program. 5. OUT OF NETWORK INSURANCE: (Initial) Except as otherwise provided by law, I understand that it is my responsibility to verify that Midwestern University Clinic a participating provider with my insurance carrier(s). I understand I will be financially responsible for all charges not covered by insurance including any and all co-payments, deductibles, and above usual and customary amounts. I understand that my insurer(s) will not pay Midwestern University Clinic s charges in full and I agree to pay Midwestern University Clinic the remaining balance. 1

10 6. APPOINTMENT OF REPRESENTATIVE AND JUDICIAL REVIEW: (Initial) I hereby appoint Midwestern University Clinic or the Clinic Operations Administrator or other representative as my duly authorized representative and assignee ( Representative ) during any (1) administrative claims process; (2) appeal or review process for a denied claim; or (3) State or Federal legal process, necessary to collect claims submitted on my behalf, but denied on my plan. I hereby authorize the Representative to take all necessary actions to resolve any disputed claim for reimbursement for services provided to me by Midwestern University Clinic, including the filing of all necessary appeals and complaints with the proper authorities and the release of all information related to the services. If my claim for benefits is administratively denied in whole or in part, I hereby assign all causes of action for judicial review and/or appeal to my designated Representative. (This means that Midwestern University Clinic may arbitrate your claim for you.) I understand that any action is in Midwestern University s sole discretion and that it may elect not to take any action. Any decision not to take action will not relieve me of financial responsibility for services provided to me. 7. PATIENT RECEIPT OF PAYMENT: (Initial) I agree to immediately sign over and send directly to Midwestern University Clinic any funds that I receive from my insurance company in connection with services provided to me at Midwestern University Clinic. This is a direct assignment of my rights and benefits under my medical policy/plan. I understand this payment will not exceed my indebtedness to Midwestern University Clinic, and I agree to pay, in a timely manner, any balance of charges over and above the payments made to Midwestern University Clinic pursuant to this assignment of benefits. 8. COLLECTION EFFORTS: (Initial) I authorize the release of any information pertinent to payment for services rendered to me by Midwestern University Clinic to any insurance company, adjuster, or attorney involved in Midwestern University Clinic s efforts to collect payment for services provided to me. 9. DUPLICATION: I permit a copy of this authorization, assignment, and acknowledgement to be used in place of the original. Patient Signature: Patient Representative Signature (if applicable): Time & Date: Patient Name: Patient Representative Name (if applicable): Relationship of Representative To Patient (if applicable): Witness Signature: Witness Name: updated 11/2014 2

11 MIDWESTERN UNIVERSITY MULTISPECIALTY CLINICS 3450 Lacey Rd. Downers Grove, IL NOTICE OF SUPERVISED STUDENT, INTERN OR RESIDENT HEALTHCARE PROVIDERS IN VOLVED IN PATIENT CARE Midwestern University Clinic is a multi-specialty outpatient medical clinic dedicated to providing high quality care to patients. Midwestern University Clinic is affiliated with Midwestern University, a University specializing in medical and health science education at its campuses located in Glendale, Arizona and Downers Grove, Illinois, with colleges of osteopathic medicine, pharmacy, health sciences, optometry, and dental medicine. It is our belief that Midwestern University Clinic s affiliation with Midwestern University allows our health care providers to keep up-to-date with the latest treatment, technology and medical innovations, which result in better treatment to our patients. Midwestern University Clinic is also a resource for the training of students, interns and residents in various health professions. Specifically, Midwestern University Clinic affords students, interns and residents studying various health professionals at the University with the opportunity to participate in the delivery of care to patients as part of their educational experience, under the supervision of experienced attending physicians. As a result, one or more of the Midwestern University s students, interns or residents may be involved in your treatment. Any student, intern or resident involved in your care will be supervised by a fully licensed physician or other licensed healthcare professional and in no case will you be seen exclusively by a student, intern or resident. Prior to the beginning of your treatment, any student, intern or resident involved in your care will be introduced and identified to you. You have the right to request that a student, intern or resident not be involved in your treatment. If you would like to make such a request, please inform the Midwestern University Clinic intake staff member who processes your patient information form and your treating physician prior to beginning treatment. If you have any questions about the involvement of students, intern or residents in patient care at Midwestern University Clinic, please contact your provider. Patient Initial Date

12 Finley Road Highland Avenue Lacey Road Main Street Midwestern University Clinics 630/ Directions to the Midwestern University Multispecialty Clinic at 3450 Lacey Road, Downers Grove, IL From I-355 Take I-355 to the IL-56/Butterfield exit Head West on IL-56W/Butterfield Road for about 0.3 miles Turn left (south) at Lloyd Ave. Enter Woodcreek Drive Keep left at the fork at Lacey Road and drive for 0.8 miles Your destination will be on your right From I-88 Take I-88 to I-355 North In 2.3 miles, take the IL-56/Butterfield exit Turn left (west) on IL-56W/Butterfield Road for about 0.3 miles Turn left (south) at Lloyd Ave. Enter Woodcreek Drive Keep left at the fork at Lacey Road and drive for 0.8 miles Your destination will be on your right Alternative Transportation: DuPage County Senior Services: 800/ York Township Senior Ride Program: 630/ The Home Depot 56 W o o d c r e e k D r i v e Bright Horizons Midwestern University Multispecialty Clinics Invesco Inc. s North Lacey Road Double Tree Suites Finley Road Packey Webb Ford 355 Fry s Electronics Ogden Avenue 34 Butterfield Road 88 31st Street 3450 Lacey Road Downers Grove, IL / Midwestern University