Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs Caffeine How often do you exercise? Never 1-2 times/week 3-4 times/week 5-6 times per week Daily Family History (Please also include any relatives with health problems) Family Member Living Deceased Age Diseases Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather
Patient Information Sheet Welcome to our Office Attention: Please fill out this form COMPLETELY, write N/A where applicable and sign it. Thank you. Social Security# First Name: Last Name: Middle Initial: Date of Birth: (MM/DD/YYYY) / / Address: Gender: Male Female Apt.#: City: Marital Status: Single Married Other State: Zip: Home Phone: ( ) Emergency Contact: Employer Name: Work Phone: ( _) Emergency Telephone#: ( _) Employer s Address / City / State / Zip Cell Phone: ( _) Primary Insurance Company Information: Policy Holder First Name: Policy Holder Last Name: Secondary Insurance Company Information: Policy Holder First Name: Policy Holder Last Name: Policy Holders SS# - - Policy Holders Date of Birth: / / Policy Holders SS# - - Policy Holders Date of Birth: / / Gender: Relationship to Policy Holder: Gender: Relationship to Policy Holder: Male Female Self Spouse Child Other Male Female Self Spouse Child Other Policy Holder s Address: Same as patient Policy Holder s Address: Same as patient City: State: Zip: City: State: Zip: Insurance s Name: Insurance s Name: Policy ID: Group #: Policy ID: Group #: Claim Submission Address: Claim Submission Address: Effective Date: / / Effective Date: / / Do you have a Co-pay? No Yes, Amt $ Do you have a Co-pay? No Yes, Amt $ Attached Copy of the Insurance Card Yes No Attached Copy of the Insurance Card Yes No Responsible Party Information Please complete if the responsible for payment is not the Patient or the Policy Holder. Responsible Party s Name (Last / First): Responsible Party s Address / City / State / Zip: Responsible Party s SSN: - - Relationship to Responsible Party: Self Spouse Child Other I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM AND HEREBY ASSIGN TO THE PHYSICIAN ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MY DEPENDENTS OR MYSELF. I UNDERSTAND THAT IT IS AS A COURTESY THAT THE DOCTOR ACCEPTS MY IN SURANCE FOR PAYMENT AND THAT IF FOR ANY REASON THEY DO NOT PAY MY BILL THAT I AM RESPONSIBLE. I have received the Confidentially Agreement (HIPAA) and agree to comply with all its terms. Today s Date:_ Responsible party s Signature: Active Management 1998 (Revised 9/24/2008)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY Uses and Disclosures Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Primary Care Physicians. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. Additional Uses of Information Appointment reminders. Your health information will be used by our staff to send you appointment reminders. Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you. Fund raising. Unless you request us not to, we will use your name and address to support our fund raising efforts. If you do not want to participate in fund raising efforts, please check off the following box. Please do not use my information for fund raising purposes. Active Management 1998 (Created 6/21/2012 by SM)
Individual Rights You have certain rights under the federal privacy standards. These include: The right to request restrictions on the use and disclosure of your protected health information The right to receive confidential communications concerning your medical condition and treatment The right to inspect and copy your protected health information The right to amend or submit corrections to your protected health information The right to receive an accounting of how and to whom your protected health information has been disclosed The right to receive a printed copy of this notice Primary Care Physician s Duties: We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain. Requests to Inspect Protected Health Information As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Privacy Officer. Complaints & Contact Person If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Primary Care Physicians, ATTN: Privacy Officer, 257-10 Union Turnpike, Glen Oaks, New York 11004. If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Patient Name (Please Print) Patient Signature Date: This Notice is effective on or after April 15, 2003 Active Management 1998 (Created 6/21/2012 by SM)
Health Screening (Please indicate if you have received that following screening test & date performed) Screening Test Yes / No Date / Results Screening Test Yes / No Date / Results Cholesterol Colonoscopy Blood Pressure Mammogram Blood Sugar Pap Smear EKG Prostate Test Review of Systems (Please circle any symptoms you have experienced recently) General Ears Eyes Nose Throat Weight Gain Hearing Loss Vision Loss Nose Bleed Hoarseness Weight Loss Ringing in Ears Blurry Vision Nasal Congestion Sore Throat Loss Of Appetite Wax Problem Painful Eyes Snoring Itchy Throat Night Sweats Ear Pain Redness Post Nasal Drip Difficulty Swallowing Fatigue Drainage Decreased Smell Painful Swallowing Swollen Glands Cardiovascular Respiratory Gastrointestinal Urinary Allergy Chest Pain Persistent Cough Nausea / Vomiting Painful Urination Sinus Congestion Irregular Heartbeat Bloody Sputum Abdominal Pain Flank Pain Hives Palpitations Difficulty Breathing Heartburn Nighttime Urination Itchy Eyes Swollen Legs Wheezing Diarrhea Urine Leakage Runny Nose Painful Legs Painful Breathing Constipation Difficulty Urinating Bloody Stools Frequent Urination Mucous in Stools Blood in Urine Rectal Pain Recurrent Uri Rectal Bleeding Neuro Skin Musculoskeletal Hematologic Psychiatric Headache Rash Joint Pain Easy Bruising Difficulties With Sleep Numbess / Tingling Itchy Skin Joint Swelling Varicose Veins Stress Memory Difficulties Dry Skin Joint Redness Excessive Bleeding Feeling Depressed Speech Problems Change in Moles Joint Stiffness Feeling Anxious Tremors New Mole Muscle Pain Changes In Mood Difficulty Walking Hair Loss Back Pain Changes In Behavior Lightheaded Heat Intolerance Suicidal Thoughts Dizzy / Vertigo Cold Intolerance Eating Disorder Fainting Domestic Abuse For Female Patients Problems with Fertility Abnormal Discharge Are you satisfied with your sexual function & desire? Yes No Menstrual History: Age of first Period Age of Menopause Frequency of Menses Date of Last Menses Pain during Menses? Yes No Heavy Bleeding? Yes No Bleeding between Periods? Yes No For Male Patients Problems with Fertility Abnormal Discharge Are you satisfied with your sexual function & desire? Yes No Pregnancy History: Number of Pregnancies Complications
Name Date of Birth Date of First Visit Reason for Visit Additional Issues you would like to address Past Medical History Yes No Condition High Blood Pressure High Cholesterol Heart Disease Diabetes Blood Clot Stroke TIA (Mini-Stroke) Seizures Headaches Migraine Headaches Depression Anxiety Hearing Loss Glaucoma Cataracts Macular Degeneration Yes No Condition Asthma Pneumonia Emphysema / COPD Positive PPD Tuberculosis Acid Reflux / GERD Stomach Ulcers Gallstones Liver Disease Diverticulitis Hemorrhoids Colon Polyps Enlarged Prostate Polycystic Ovaries Irregular Menses Cancer Yes No Condition Kidney Stones Urinary Infection Kidney Disease Arthritis Lupus Gout Psoriasis Osteoporosis Thyroid Disorder Anemia Bleeding Disorder Blood Transfusion Neck Disorder Back Disorder Allergies Other Medical Conditions Medications Please list all prescriptions and over the counter medications / supplements that you are taking Name of Medication Dosage How Often Date Started