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Patient Information Form (Back
to Patient Information Form)
Name: ______________________________________
DOB: __________
Age: _________
Mailing Address:
_______________________________________________________________________
Home Address:
________________________________________________________________________
Home #:_______________________
Work #:____________________
Cell #:______________________
E-mail:___________________________
SS#: __________________
Driver's
Lic.:____________________
Spouse: ___________________________________ Tel: ____________________________
Guardian
(if applicable):__________________________ Tel: ___________________________
Person to
contact in case of emergency (and relationship to you):
________________________________________________
Tel: ___________________________
Occupation:
_____________________ Employer: _____________________
Tel: ____________________
Primary Physician:
_______________________________ Tel: ___________________________
Insurance
Company: ___________________________________________________________________
Insurance
Identification Number: __________________________________________________________
Name of Insured:
_______________________________________________________________________
Group Policy
Number: ___________________________________________________________________
Chief Complaint (CC):______________________________________________
History of
CC (what, when, why, where, how, time, alleviated by, aggravated by):____________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Additional
Complaints (head, neck, chest, breasts, arms, hands, abdomen, pelvis,
genitalia,
legs, feet, cough, hemorrhoids, constipation, congestion, pain, etc):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Goals: _________________________________________________________________________________
Medications-including
herbs, supplements, remedies: ___________________________________________
______________________________________________________________________________________
Allergies:
______________________________________________________________________________
Drug Reactions:
_________________________________________________________________________
Previous
care taken for this CC: ____________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Past Medical
History:
__measles __hypertension __rheumatic fever __headaches __cancer
__mumps __heart disease __scarlet fever __migraines __depression
__rubella __kidney disease __tuberculosis __Candida __ulcers
__hives __UTI __immune disorder __glaucoma __hepatitis
__eczema __liver disease __thyroid disease __heart murmurs
__anemia __bleeding disorder __gallbladder dis. __blood clots __insomnia
__asthma __pneumonia __Epstein Barr __edema __diabetes
__stroke __seizure __venereal disease __other (explain)
_____________________________________________________________________________________
_____________________________________________________________________________________
Past Surgical
History:
__tonsils __adenoids __appendix __uterus __tooth extraction
__ovaries __eye __neck __chest __skin excision
__abdomen __gallbladder __bowel __breast __circumcision
__fractures __stitches __bunions __scars __other (explain)
____________________________________________________________________________________
____________________________________________________________________________________
Hospitalizations:
_______________________________________________________________________
_____________________________________________________________________________________
Accidents/trauma/injuries-even as a child-(Motor vehicle, sporting, pedestrian):
______________________________________________________________________________________
______________________________________________________________________________________
Family History
(paternal, maternal, siblings):
__asthma __diabetes __glaucoma __hypertension __cancer
__depression __alcoholism __psychological __kidney disorder
__immune disorder __arthritis __other (explain)
Travel History (where, when, how long, illness? frequency):______________________________________
______________________________________________________________________________________
Social history:
Eating habits/diet:
_____________________________________________________________________
Tobacco use-present
and past (how much, how long, how often):_______________________________
Alcohol use-present
and past (how much, how long, how often):________________________________
Caffeine
use-present and past (How much, how long, how often):_______________________________
Exercise/activities/sports:
_______________________________________________________________
Sleeping habits: _______________________________________________________________________
Marital status: ________________________________________________________________________
Children
(natural, adopted, mixed family):__________________________________________________
Relatives
living in the household: _________________________________________________________
Job related
activities: __________________________________________________________________
Pregnancy:
Number: _______ Living: _______ Menses/ Age at onset: _______
Duration:
______Complications: _______________________
Date of last menstrual period: ________
Medications: ________________________ Associations: _______________________
Delivery (surgical, natural, induced):_______ Age of menopause: _________________
Medications: _________________________ Associations: _____________________
Episiotomy/tear: _____________________
Last Pap
(and results):______________________
Last mammogram (and results):_______________
Orthosis/prosthesis:
____________________________________________________________________
Contact lens/glasses:
__________________________ Last eye exam: ____________________________
Laboratory
and radiographic studies performed: _____________________________________________
____________________________________________________________________________________
Other: _______________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
I have read
and agree to the following:
OFFICE POLICIES:
Office visit
is by appointment only. Your appointment time is set aside for you. If
you
must
cancel or change an appointment, please notify us as soon as possible
so that
the time may be used to help another person. You will be responsible for
a cancellation
charge of $45.00 for an appointment not cancelled 24 hours in advance.
Patients
must be under the care of a physician for any pre-existing health problems
and are responsible for keeping this office informed of the current name,
address, and
telephone number of such physician.
Any criticism
or complaint about the office, its practitioners, or its practices are
welcomed
and appreciated.
Signature: _________________________________ Date: ________________
PAYMENT POLICIES:
I hereby
assume full financial responsibility for and agree (regardless of my insurance
status) that I am ultimately responsible for the full payment on my and
/or my dependant's
accounts for all charges for professional services rendered and medical
supplies received.
Full payment
is due at the time that services are rendered.
I understand
that a medical insurance contract is a contract either between and
individual and the insurance company or between the employer for whom
the individual
works or is affiliated and the insurance carrier. This contract does not
involve a contract
between the physician and the insurance carrier. Such a contract has been
known to
interfere with the doctor-patient relationship. The office is therefore
unable to accept
payment from insurance programs. The patient will receive a copy of the
"super bill"
which has all of the necessary information for insurance processing. This
is to be either
submitted or transcribed on the individual insurance company forms. If
further assistance
is needed in completing the insurance forms, please contact this office.
Whether your insurance company pays in full, a portion, or no part of
your medical bills
is a matter between you and your insurance carrier.
This office
is not responsible for the collection of your insurance claim or for negotiating
a settlement on a disputed claim, but will help out in the form of letters
and explanations
when necessary.
I agree that
I am responsible for the reasonable fees that will be charged for any
and all
services and fees connected with investigation, litigation or collection.
I agree that
I am responsible for customary bank fees charged for returned checks or
for
insufficient funds.
I permit
a copy of this authorization and agreement to be used in place of the
original.
Signature:
______________________________ Date: ___________
REPORTS AND FORMS:
I authorize
the release of medical information required by my insurance carrier or
its
designated review agent in order to process any insurance claim for benefits.
This author-
ization may be revoked or changed by me in writing at any time. There
may be a fee of
charged for dictation, filing of long reports, or excessive photocopying.
This fee will be
proportionate to the amount of time charged for an office visit. I am
responsible for this fee
should it apply.
A copy of
this authorization will be deemed as valid as the original authorization.
Signature: _____________________________ Date: _______________
PATIENT PRIVACY:
New regulations for HIPPA are out. This office, though exempt because
there are no third
parties in our interaction and no electronic claims are being made, will
present a written
patient privacy policy. We make every effort to ensure that the privacy
of you medical record
is maintained. To help us do this, we ask that:
1. All requests
for medical records be made in writing. For your convenience a standard
medical release form is available.
2. Medical record be sent by mail, rather than fax, to a designated person.
3. You not discuss sensitive medical information with non-medical personnel,
leave such
information on the answering machine, or send such information via email.
For that
same reason, Dr. Chun will not leave information on a message machine
nor will
she respond to medical questions via email.
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