LVPG INTERNAL MEDICINE Phone 484-661-4650 Fax 610-402-1153 3080 Hamilton Boulevard, Suite 350 Allentown, PA 18103 Office Hours: Monday: 8:00 a.m. 9:00 p.m. Tuesday Friday: 8:00am 5:00pm WELCOME TO OUR PRACTICE Welcome to LVPG Internal Medicine. We are primary care doctors and nurse practitioners who care for people ages 16 and up. The physicians, medical staff and office personnel want you to know that we are dedicated to providing quality healthcare and personal service with a team approach -- doctors and nurse practitioners work together as your personal health care team. You will still have a primary doctor or nurse practitioner, but if your provider of choice is not available, you will have the option to see another physician or nurse practitioner in the group. We also use an electronic medical record, which means all of our practitioners can easily be brought up-to-date on your health and your care. We want to make your visits with us as pleasant as possible and look forward to you joining our practice. ABOUT OUR OFFICE Our practice includes eleven physicians and two nurse practitioners. The physicians have teaching positions at the University of South Florida Health, Morsani College of Medicine and are actively involved in the Lehigh Valley Hospital Internal Medicine residency program to teach and prepare future physicians. As a part of this teaching process, during visits with your physician, you may be asked to also be seen by a medical resident or medical student. REGISTRATION FORM Please complete the enclosed forms prior to your visit and mail them back in the stamped envelope. For each visit, please bring a list of your current medications, current dose and any refills that may be needed. APPOINTMENT TIME For your first visit, please arrive 30 minutes prior to your scheduled appointment time to complete the registration process. Please bring your insurance cards, and insurance referral (if applicable) with you. OFFICE FEES Payment is expected at the time of your visit. We accept cash, checks, Traveler s checks, VISA, MasterCard, American Express and Discover. Attached is a list of participating insurances. For the commercial insurances not listed, we do accept most, but it is your responsibility as the patient to pay for the cost of the visit at the time of service and submit for reimbursement through your insurance company. WHEN YOU CALL US When you call the office, you will be prompted to make a selection. The nurses and medical assistants will handle all of your calls dealing with prescriptions, medical questions, and ill appointments. The front office staff will assist you with other questions including billing and appointment information. EMERGENCIES We are available for emergencies 24 hours a day, 7 days a week. After hours, an answering service operator will page the physician on-call. The doctor will respond within 15 minutes. For non-urgent issues such as prescription refills and appointments, the service will advise you to call the office during regular office hours. REFERRALS AND PRESCRIPTIONS The office requires prior notice for the processing of referrals, pre-certifications and prescriptions: 48 hours notice Referrals, prescriptions** 72 hours notice Pre-certifications **Note--7 days are needed for the processing of mail order prescriptions and narcotic medications. If you are low on a medication and will not receive your mail order in time, we will call-in a 30-day supply to a local pharmacy. **For more information please visit our website at www.lvpginternalmedicine.com, or feel free to ask any of the staff here at LVPG Internal Medicine.
PLEASE RETURN THIS FORM TO THE RECEPTIONIST PATIENT INFORMATION DATE LAST NAME FIRST NAME MI ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE MALE FEMALE DATE OF BIRTH MARITAL STATUS SS# EMPLOYER INFORMATION PATIENT EMPLOYER OCCUPATION EMPLOYER ADDRESS PHONE NUMBER REFERRING DOCTOR INFORMATION FAMILY DOCTOR PHONE NUMBER REFERRING DOCTOR PHONE NUMBER SPOUSE INFORMATION LAST NAME FIRST NAME MI DATE OF BIRTH SS# WORK NUMBER EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT NAME PHONE NUMBER RELATIONSHIP NEXT OF KIN IF PATIENT IS A MINOR MOTHER S NAME SS# DATE OF BIRTH FATHER S NAME SS# DATE OF BIRTH INSURANCE PRIMARY SECONDARY NAME (IF OTHER THAN SELF) EFFECTIVE DATE GROUP # SEE ATTACHED COPY OF INS CARD SEE ATTACHED COPY OF INS CARD SUBSCRIBER SEE ATTACHED COPY OF INS CARD SEE ATTACHED COPY OF INS CARD (OFFICE USE ONLY) MEDICAL RECORD NUMBER
LVPG Medical Information Communication Preferences Patient MR# DOB / / As our patient, we may need to communicate with you when you are not in the practice. To assure your privacy, we would like you to indicate your preferred method for us to communicate medical information to you and/or to others involved in your care. Please note that an appointment reminder is not classified as medical information. PLEASE INDICATE YOUR COMMUNICATION PREFERENCES BELOW: I give permission to leave medical information pertaining to me, my dependent or child, at the numbers listed below: Method Yes No Area Code, Phone #, Extension Home Answering Machine Work Phone Cell Phone Pager Without specific permission, we will not release any medical information to anyone other than you. In some cases you may wish for another person to have access to your medical information. Please identify those individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner etc.): Do not release medical information to anyone other than myself. I give permission to release medical information pertaining to me to the individuals listed below. Name Relationship (i.e. spouse, parent, son, daughter, etc.) Area Code, Phone # - Extension Comments I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to revoke this specific medical information authorization at any time. Signature of Patient or Patient s Legal Representative Date (Please Print Signer s Name)
PATIENT NAME: DOB: / / MR#(OFFICE USE ONLY) Your Present Medical History Please check the symptoms that you currently or recently have had: A. Skin Rash Hives New skin growth A sore that does not heal Growths that have changed size or color Yellowing of the skin Purple, pink, or brown spots on the body B. Eyes Cloudy vision Seeing spots or floaters Double vision Eye pain Vision changes Yellowing of eyes Dry, scratchy eye C. Ears, Nose, and Throat Hearing loss Drainage from ears Frequent ear pain Ringing in the ears Sinus trouble Post nasal drip Frequent nose bleeds Loss of sense of smell Snoring Hoarseness Problems swallowing Ulcerous growth in mouth Chronic sore throat Tooth or gum pain D. Lungs Pain on breathing Wheezing Chronic cough Coughing up phlegm Shortness of breath (including when asleep) Frequent colds Sleeping with head raised on pillows to help you breath E. Heart and Blood Vessels Heart murmur Leg cramps after walking Leg cramps waking you at night Swollen ankles Getting up at night to urinate Night sweats Getting up at night short of breath Chest pain or tightness Fainting or dizziness Rapid heart beat Irregular heart rate F. Stomach and Intestines Heartburn/Indigestion Belly pain Trouble or pain swallowing Constipation Diarrhea Excess gas or frequent belching Blood in bowel movement or on toilet tissue Loss of bowel control Black bowel movements Increased thirst Increased hunger Decreased hunger Frequent upset stomach or vomiting Change in bowel habits Burning pain in stomach between meals Weight loss in last six months Weight gain in last six months
G. Kidney and Bladder Feeling that you do not empty bladder completely Dribbling after urination Difficulty starting or stopping urination Burning after urination Loss of control of urine H. Muscles and Bones Joint pain Back/Neck pain Pain with movement I. Nerves and Brain Headaches Loss or change in eyesight Weakness in arms or legs Memory loss Anxiety Seizures Confusion J. Men Only Discharge from penis Problems getting or keeping an erection Pain or swelling in the testicles K. Women Only Lump in breast Discharge from vagina Blood in urine Joint stiffness Bone Pain Dizzy spells Loss or change in speech Numbness in arms or legs Problems with balance Nervousness Depression Pain during sex Lump in testicles Irregular periods Pain during sex Leaking of urine when coughing, sneezing, laughing, or doing activities Do you examine your breasts regularly? Yes No When was your last menstrual period? L. Date of Last Immunizations: Tetanus vaccine: Hepatitis B vaccine: Pneumonia vaccine: Measles, Mumps, Rubella vaccine: Hepatitis A vaccine: Varicella vaccine: M. Did you have the chicken pox? Yes No YOUR HEALTH IS VERY IMPORTANT TO US, IT S IMPORTANT THAT YOU COMPLETE THIS FORM ACCURATELY, AS ANY MISSING INFORMATION CAN AFFECT YOUR HEALTH. PATIENT SIGNATURE:
PATIENT NAME: DOB: / / MR#(OFFICE USE ONLY) Social History What Advance Directives do you have in place: Living Will If you would like more information regarding advanced directives, please ask the receptionist Birth Place: Level of Education: Occupation: Previously Widowed? Y / N Do You Have Children? Y / N How many sons Previously Divorced? Y/ N How many daughters Lifestyle Type of Exercise: Hobbies/ Activities: Diet History: Tobacco:Yes No Former Year Quit Type Amount per day How many years did you smoke? Alcohol: Yes No Former Year Quit Type Amount per day Caffeine:Yes No Former Year Quit Type Amount per day Illicit Drug Use: Yes No Former Year Quit Type Safety Risk Factors Please read the following list of risk factors for AIDS and hepatitis. If you have any of these risk factors present, your doctor will be glad to discuss these factors with you privately. After reading the list, check the risk factors that apply to you and check the Yes or No box at the bottom of this page that applies to you. Sexual contact with a gay or bisexual male More than one sexually transmitted disease Many sexual partners Employed in a health field Worked as a prostitute History of intravenous drug use Sex with a prostitute Blood transfusion or blood products between 1978 Yellow jaundice or hepatitis Lived or traveled outside of the United States I have one or more risk factors I am sexually active YES NO I have none of the risk factors above I practice safe sex YES NO
PATIENT NAME: DOB: / / MR#(OFFICE USE ONLY) Lung Problems What Kind of Disease? Year Diagnosed Past Medical/Surgical History Procedure/Surgery Year Performed Location Heart attack/heart disease Stroke Congestive heart failure Diabetes High Blood Pressure Cancer Stomach Problems/Heartburn Bloating/Constipation Kidney/Bladder Problems Arthritis/Joint Pain/Back Pain Headaches/Seizures
PATIENT NAME: DOB: / / MR#(OFFICE USE ONLY) Diagnostic Studies Performed Diagnostic Study Yes Date(s) Performed Where Result (Abnormal, Normal, or actual result if known) Cardiac Studies Cardiac Catheterization Echocardiogram EKG Stress Test Cardiac Studies Cardiac Studies Gyn/GU Studies Mammogram PAP Smear Bone Density PSA Gyn/GU Studies Gyn/GU Studies Studies Nuclear Scans Ultrasounds CT Scan X-Rays X-Rays MRIs Colonoscopy Part of Body
PATIENT NAME: DOB: / / MR#(OFFICE USE ONLY) Family History For each family member please check the information that applies to his/her health. Family Member Father Age/ Living/ Deceased/ Age at Death Alzheimer Asthma Alcoholism Cardiac disease Cancer Type Diabetes High Cholesterol Mental Illness/Type Migraine/ Headache Kidney Disease Seizure Disorder High Blood Pressure Stroke Mother Brother Brother Brother Sister Sister Sister Mother s Mother Mother s Father Father s Mother Father s Father
Allergy and Medication Information Allergies No Known Allergies No Known Drug Allergies Medication / Ingredient: Reaction: Onset Date (if known) Medications Pharmacy Name and Location: List all medications the patient is currently taking. Include vitamins, herbals, and over the counter medications. Date Medication Dose Directions Started Ordered by T I E N T H E A
\ PATIENT HEALTH QUESTIONNAIRE 9 (PHQ 9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer) Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless 0 1 2 3 that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 FOR OFFICE CODING 0 + + + =Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.