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Transcript of *-66-//--&P.,,-G&)-054,4I;2.,&$//42;.:-/ · 0 ).# *1 %' ( $ " 1 '"#()*+,$"#$" '-."()"&$,%&...
PLEASE PRINT (Please use Black or Blue Ink ONLY) Patient Information Form
Patient Name: Date:
Address: City: State: Zip:
Home Phone: ( ) Cell Phone: ( )
Work Phone ( ) Ext. Preferred Contact:
SS#: - - Sex: M or F Age: Date of Birth: / /
Married□ □Divorced □Separated □Widowed □Single Email:
Patient’s Employer: Occupation:
Employer’s Address:(Please provide Account Guarantor’s Information, when the patient is a minor)
Spouse or Account Guarantor’s Name: Date of Birth: / /
SS#: - - Occupation:
Employer: Phone: ( )
Notify In Case of Emergency: Relationship:
Phone: ( ) Cell Phone: ( )
Result of on the job injury: Result of Accident: Date of Injury:
(Provide Guarantor’s Information only when patient is a minor otherwise provide patient’s information) PRIMARY INSURANCEInsurance Name: Relationship to Patient:
Copay Amount:
Group#:Subscriber’s Date of Birth:
Employer’s Phone:
Subscriber’s Name:
Subscriber ID/Contract/Policy#:Subscriber’s Social Security#:
Subscriber’s Employer:
Insurance Name: Relationship to Patient:Copay Amount:
Group#:Subscriber’s Date of Birth:
Employer’s Phone:
Subscriber’s Name:
Subscriber ID/Contract/Policy#:Subscriber’s Social Security#:
Subscriber’s Employer:
SECONDARY INSURANCE
PERSON RESONSIBLE FOR THIS ACCOUNT Phone: ( )When applicable, I agree that payment will be made at the time of service. I agree to pay all co-pays, non-covered or routine charges, deductibles and co-insurance amounts that apply. In the event this account is turned over to a collection agency for collection, I will be responsible for all collection fees, court costs, or attorney’s fees. I authorize Huntsville Hospital Neurological Associates to release information to insurance carriers and for insurance carrier’s torelease information to Huntsville Hospital Neurological Associates concerning my illness, treatment and paymentshereby assign to the physicians all payments for medical services rendered to myself or my dependents if assignments applies.
Signature of Responsible Person Date Time:
□ □□Home Phone Cell Phone Letter
Tennessee Valley Neurological Associates
Preferred Language
Notify In Case of Emergency: Relationship:
Phone: ( ) Cell Phone: ( )
(including workmen’s compensation) and I
Referring Physician: Family Physician:
WHAT ARE YOUR MAIN CONCERNS OR QUESTIONS TODAY?
DESCRIPTION OF PRESENT ILLNESS
CURRENT MEDICATIONS
PAST MEDICAL HISTORY
DRUG ALLERGIES
HISTORY AND PHYSICALName SS # DateAddress Phone (Home) (Work)
Date of Birth
Referring Physican
When did your symptoms start?
Medications Reactions1)2)3)
Name Dose Name Dose
HeadacheEpilepsy / SeizuresStrokeHead Injury / Concussion / WhiplashSpinal Cord Injury Arthritis _______________ (type)Peripheral NueropathyBrain TumorDepression or AnxietyCoronary Artery Disease / MIIrregular Heartbeat / Atrial FibrillationCongestive Heart FailureMurmurHigh Blood Pressure
COPD / EmphysemaPneumoniaAsthmaGERD / Acid RefluxColon PolypsBleeding DisorderAnemiaDiabetes __________ (type)Peripheral Vascular DiseaseThyroid DiseaseMenstrual / Sexual DysfunctionOther EndocrineLiver Disease / HepatitisKidney ProblemsBladder ProblemsPolioRheumatic FeverAllergy / Hay Fever
Other ____________________
Carotid Artery Disease
CHART # ________________TVNA
Maximum Printing 990-7910
Email Primary Care Physican
Reason for visit
Fibromyalgia
Autoimmune Disease (Lupus, etc.)High CholesterolSleep Apnea
Cancer ______________ (type)TuberculosisHIV / AIDSAlcohol Use: # drinks per day ________ # drinks per year ________Smoking: Current or past smoker # packs per day ________ # packs per year ________
PAST SURGICAL HISTORY
AmputationAV Fistula CreationAV GraftAortic Valve ReplacementAppendectomyLegs Bypassed Right / LeftBack SurgeryBronchoscopy (Lung Scope)CABG (Heart Bypass)Carotid EndarterectomyCarpal Tunnel Right / LeftCataract ExtractionGallbladder RemovedColon ResectionCraniotomyGastric BypassHemorrhoidectomyHip Replacement Right / Left
Kidney Transplant Knee ArthroscopyKnee Replacement Right / LeftKyphoplastyLumpectomy
Invasive Pain Procedure
Mitral Valve ReplacedNephrectomyPacemaker ImplantedParathyroidectomyPneumonectomyPTCA (Angioplasty)Rotator Cuff Repair Right / LeftAbd. HysterectomyHysterectomy/Ovaries**Ovaries Removed Yes / NoProstate SurgeryShoulder Surgery Right / LeftSleep Apnea SurgeryThyroid SurgeryTonsil’s RemovedVascular SurgeryBreast Augmentation Right / LeftMastectomy Right / LeftLumpectomy Right / LeftOther ____________________
__________________________
Latex Allergy: Y___ N___
Advanced Directives: Y N(Please provide office a copy for their records)
PRIOR HOSPITALIZATIONSReason
REMARKS
FAMILY HISTORY
Heart Disease
Hypertension
Diabetes
Cancer
Arthritis
Bleeding Disorder
Kidney Disease
Thyroid Disease
Seizures
Stroke
Mental Illness
Dementia
Neuromuscular
Headaches /Migraine
Autoimmune Disease
REHTAF
REHTOM
S’REHTAF
STNERAP
S’REHTOM
STNERAP
Completed by: Date:
BROTHER
SISTE
R
SONDAUGHTE
RREHTAF
REHTOM
S’REHTAF
STNERAP
S’REHTOM
STNERAP BROTHER
SISTE
R
SONDAUGHTE
R
FeverChillsSweatsAnorexiaFatigueWeaknessMalaiseWeight LossSleep Disorder
REVIEW OF SYSTEMSGENERAL
BlurringDouble VisionIrritationDischargeVision LossEye PainSensitivity to Light
EYES
EaracheEar DischargeRinging of EarsDecreased HearingNasal CongestionNosebleedsSore ThroatHoarseness
ENT
Chest PainsPalpitationsSyncopeShortness of Breath on ExertionOrthopneaPNDPeripheral Edema
CVCoughDyspnea at RestExcessice SputumCoughing Up BloodWheezingShortness of Breath at Rest
RESP
NauseaVomitingDiarrheaConstipationChange in Bowel HabitsAbdominal PainBlood in StoolJaundice
GI
Gas/BloatingIndegestion/HeartburnTrouble SwallowingPainful Swallowing
Painful UrinationBlood in UrineDischargeUrinary FrequencyUrinary HesitancyNightime UrinationIncontinenceGenital SoresDecreased Libido
GU
Erectile Disfunction
Back PainJoint PainJoint SwellingMuscle CrampsMuscle WeaknessStiffnessArthritisSciatica
Restless Legs
MS
RashItchingDrynessSuspicious Lesions
DERM
DepressionAnxietyMemory LossSuicidal IdeationHallucinationsParanoiaPhobia
PSYCHCold IntoleranceHeat IntoleranceExcessive ThirstExcessive HungerExcessive UrinationUnusual Weight Change
ENDO
Bruse EasillyDifficulty Stopping BleedsEnlarged Lymph Nodes
HEMEHivesAllergic RashHay FeverRecurrent Infections
ALLERGY
Leg Pain at NightLeg Pain With Exertion
Confusion
Cancer Type?
Murmur
High Cholesterol
Asthma
Sudden Death
Rheumatic Disease
Anemia
Glaucoma
Neuromuscular
TB
AIDS
Wear Glasses/Contacts
CataractsLast Eye Exam _______
AllergiesSinus TroubleGoiter/ThyroidSwollen Glands
Chest Pain w/exerciseSwelling of AnklesLast EKG_______
Emphysema/BronchitisPneumoniaHemopysis
UlcerHemorrhoidsHepatitis
Leakage of UrineKidney StonesFrequent Infections
Phlebitis
Numbness/TinglingVaricose Veins
Hair/Nail ProblemsLumpsMasses
HeadachesDizziness
NEURO
HypothyroidHyperthyroidDiabetes
Seasonal AllergiesALLERGIES
LumpsNipple DischargeDo Self Exam
BREASTYellow JaundiceFamily History ofBleedingBlood Transfusion