patient information form a - Arthritis Associates of the Main Line, PC

PATIENT INFORMATION FORM Arthritis Associates of the Main Line, PC 11 Industrial Blvd, Suite 201, Paoli, PA 19301 Phone: 610‐647‐2398 Fax: 610‐993‐2867 First name MI Last name Date of birth Age Sex Address City State Zip Home Phone Work Phone Cell Phone Email Address S M D W Marital status Social security number Employer Spouse’s employer ________________________________________________________________________________________________________________________ Primary Care Physician Phone number Referring physician Phone number EMERGENCY CONTACT: ___________________________________________RELATIONSHIP: ______________________ PHONE NUMBER(S):_________________________________________________________________________________ PRIMARY INSURANCE________________________________POLICY NO/GROUP__________________________________________ Subscriber: _________________________________________Date of birth: ________________Relationship to patient:___________ SECONDARY INSURANCE_____________________________POLICY NO/GROUP___________________________________________ Subscriber: _________________________________________Date of birth: _______________Relationship to patient: ___________ Preferred pharmacy________________________________________________ phone number______________________________ Mail order pharmacy______________________________________phone ______________________fax______________________ ASSIGNMENT OF BENEFITS I REQUEST THAT PAYMENT OF AUTHORIZED INSURANCE OR MEDICARE BENEFITS BE MADE ON MY BEHALF TO ARTHRITIS ASSOCIATES OF THE MAIN LINE, PC, FOR ANY SERVICES FURNISHED TO ME BY PHYSICIAN/SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION TO RELEASE TO THE INSURANCE COMPANY OR TO CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE TO RELATED SERVICES. I AUTHORIZE RELEASE OF ALL MEDICAL INFORMATION WHICH IS NECESSARY TO PROCESS MY INSURANCE CLAIMS AND WHICH IS PERTINENT TO MY MEDICAL CARE. I ASSIGN ALL MEDICAL BENEFITS TO WHICH I AM ENTITLED TO ARTHRITIS ASSOCIATES OF THE MAIN LINE, PC. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ THIS INFORMATION AND I UNDERSTAND IT. Print name____________________________________________________________________ Signature_____________________________________________________________________Date____________________ PAST MEDICAL HISTORY Please indicate if you have ever experienced any of the following conditions. Please include the year. Constitutional: o High cholesterol o Irregular heart rhythm o Hypertension o Other Gastrointestinal: o Celiac disease o Colitis o Crohn’s HEENT: o Diarrhea o Hearing loss o Iritis o Esophageal reflux o Oral/nasal ulcers o Gall stones o Tinnitus o Hepatitis o Uveitis o Irritable bowel o Vision loss o Kidney disease o Other o Kidney Stones o Liver disease o Ulcer Respiratory: o Other o Asthma o Chronic bronchitis Metabolic/Endocrine: o Chronic sinusitis o Diabetes Type I o COPD Type II o Emphysema o Goiter o Tuberculosis o Hyperthyroidism o Other o Thyroid disease o Other Cardiovascular: Neuro/Psychiatric: o Angina o Chest pain o Anxiety o Circulatory disease o Confusion o CHF o Depression o Heart attack o Headaches o Heart disease o Memory impairment o Heart failure o Migraines o High blood pressure o Seizures/epilepsy o
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Allergies Cancer Chronic fatigue Fevers Insomnia Sleep apnea Other o
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Stroke (CVA) Other Dermatologic: o Hair Loss o Photosensitivity o Psoriasis o Rash o Nodules o Other Musculoskeletal: o Calcinosis o Chronic neck pain o Disc degeneration o Fractures o Gout or gouty deposits o Joint pain o Joint stiffness o Joint swelling o Joint warmth o Osteoarthritis o Osteoporosis o Rheumatoid Arthritis o Raynaud’s o Sciatica o Other Hematologic: o Anemia o Blood clots o Hemorrhage o Other SURGICAL HISTORY Please check all that apply. Please include the year. o
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Angioplasty Cholecystectomy Liver Biopsy Angioplasty w/ stent Colectomy Pacemaker Appendectomy Colostomy Patient’s Name Signature o Small bowel resection o Arthroscopy o Gastric bypass o Thyroidectomy o Back surgery o Hernia repair o Tonsillectomy o Hip Replacement o
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Coronary artery bypass graft Carpal tunnel release Hysterectomy Cataract extraction Knee replacement Other Date Physician Initials FAMILY HISTORY Please check if any family member has had any of the following conditions and the age of onset. Adopted Mother Father Siblings Grandparents Children Cause of Death Blood disease ____________________________________________________________________ Cancer ____________________________________________________________________ Gout ____________________________________________________________________ Heart disease ____________________________________________________________________ IBS ____________________________________________________________________ Kidney disease ____________________________________________________________________ Lupus or SLE ____________________________________________________________________ Osteoarthritis ____________________________________________________________________ Osteoporosis ____________________________________________________________________ Psoriasis ____________________________________________________________________ Rheumatoid arthritis ____________________________________________________________________ Stroke (CVA) ____________________________________________________________________ SOCIAL HISTORY Tobacco use? ________ Packs per day? __________ Years smoked? ___________ Year quit? ________ Alcohol use? ________ Type? _________________ Amount/week? ___________Year quit? _________ Ethnicity: o Hispanic or Latino o Not Hispanic or Latino Preferred Language: Race: o
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American Indian or Alaska Native Asian Black Indian Multi‐Racial Native Hawaiian or Other Pacific Islander Other Race White ADULT IMMUNIZATIONS AND DATE Pneumococcal (PPV23) Herpes Zoster (Shingles) Influenza/H1N1 ALLERGIES/ No Known Allergies Medications: IV contrast? ____________ Shellfish? ____________ Latex? ____________ Other? CURRENT MEDICATIONS Other (Please list all prescription and non‐prescription medications, with dosage.) 1._________________________________________________ 5.______________________________________________________ 2._________________________________________________ 6.______________________________________________________ 3._________________________________________________ 7.______________________________________________________ 4._________________________________________________ 8.______________________________________________________ Patient’s Name Signature Date Physician Initials