Age: Birthdate: Date of Last Physical Exam

Name: Date:

Age: Birthdate: Date of Last Physical exam:

SYMPTOMS: Check  symptoms you currently have OR have had within the past YEAR.

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Signature Date

Reviewed By Date

College Station Surgical Associates

Henry E. Bohne, MD, FACS  John W. Williams, MD, FACS  David C. Gochnour II, MD

General

Fever
Chills
Night sweats
Weight Gain
Weight Loss
Exercise intolerance
Sleep Disturbances
Insomnia
Loss of appetite

Eye

Dry Eyes
Irritation
Pain
Visual changes
Light sensitivity
Seeing double
Discharge

ENMT

Difficulty hearing
Ear Pain
Vertigo
Ringing in Ears
Runny Nose
Nasal Congestion
Frequent sneezing
Sinus Pressure
Difficulty smelling
Nosebleeds
Sore throat
Difficulty swallowing
Bleeding Gums
Snoring
Vocal changes
Dry Mouth
Mouth Ulcers
Oral Abnormalities

Cardiovascular

Chest pain
Shortness of Breath When Walking
Murmur/ Palpitations
Light headedness
Pain in Calves/Jaw
Pain in Ankles

Respiratory

Cough
Wheezing
Shortness of Breath
Rapid Breathing
Sputum Production
Coughing Blood
Sleep Apnea

Gastrointestinal

Nausea
Vomiting
Vomiting Blood
Abdominal Pain
Diarrhea
Appetite change
Constipation
Heartburn

Genitourinary

Pain While Urinating
Incontinence
Difficulty Urinating
Hematuria
Urinating Frequently
Flank Pain
UTI

Musculoskeletal

Muscle Aches
Weakness
Cramps
Joint Pain
Back Pain
Swelling of Extremities
Difficulty walking

Skin

Excessive Sweating
Excessive Facial or Body Hair
Jaundice
Itching/Rash
Discoloration
Dry Skin
Abnormal Mole
Hair Thinning
Growths/Lesions

Neurological

Loss of Consciousness/Balance
Numbness
Tingling
Tremors
Seizures
Dizziness
Headaches
Slurred speech
Memory lapses

Psychological

Irritability
Depression
Anxiety
Paranoia
Panic Attacks
Sleep Disturbance
Suicide Thoughts

Endocrine

Fatigue
Heat/Cold Intolerance
Bruising
Swollen Glands
Clotting/Bleeding Disorders

Hematologic/

Bruising
Swollen Glands
Clotting Problems
Bleeding Disorder

Allergies

Itching
Hives
Runny Nose
Congestion
Sneezing
Sinus Pressure

MEN Only

Breast Lump
Erection Difficulties
Lump in testicles
Penis Discharge
Sore on Penis
Other

Women Only

Abnormal Pap Smear
Bleeding between periods
Breast Lump
Extreme Menstrual Pain
Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge

Do you feel safe in your relationship? Y N

Date of Last

Menstrual Period:

Date of Last

Pap Smear:______

Have you had

a Mammogram?

Are you Pregnant? Y N

Number of Children

Signature Date

Reviewed By Date

CONDITIONS Check  conditions you have OR have had in the past.

AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
Prostate Problem
Psychiatric Care
Rheumatic Fever
Scarlet Fever
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis
Ulcers
Vaginal Infections
Venereal Disease

Name: Date of Birth:

Surgical/Hospitalization History:

1. 5.

2. 6.

3. 7.

4. 8.

Past Medical History: List all medical conditions (Past & Present) managed by a Physician:

1. 5.

2. 6.

3. 7.

4. 8.

Medications (including Non-Prescription Drugs):

1. 5.

2. 6.

3. 7.

4. 8.

Medication Allergies:

Social History:

Marital Status: S M W D (Circle One) Occupation:

Education:

Do you use Tobacco Products? How Much?

Do you Drink: How Much/Type?

Have you OR Do you use Illicit Drugs? Type:

Family History:

Father - Age: State of Health:

If deceased, Age and Cause:

Mother - Age: State of Health:

If deceased, Age and Cause:

Brothers/Sisters - Age: State of Health:

If deceased, Age and Cause:

Any Illnesses that seem to run in the family:

PLEASE FILL IN ALL QUESTIONS AND PRINT CLEARLY Today’s Date:

Patient SS: Date of Birth: Cell Phone:

Patient Name: Home Phone: Email:

Patient Address: City: State: Zip:

Sex:___Male ____Female Status: ____ Single _____ Married _____Divorced ___ Widowed

Employer Information:

Patient Employer: Department:

Employer Phone Number: Ext: ______

Spouse Information:

Spouse Name: Spouse Contact Phone:

Spouse SS # Date of Birth:

Person to Contact in Case of Emergency:

Name: Home Phone: Work Phone:

If Minor – Please complete:

Parent/Guardian: Contact Phone:

Relationship to Patient: Email:

Address: City: State: Zip:

INSURANCE INFORMATION

Insurance Coverage: Yes No Cash Medicaid Medicare

Is This Workers Compensation? / Accident Related? _____ Yes _____ No

Date of Accident: Auto Work Other:

PRIMARY COVERAGE

Insured Party: Self Spouse Other/ Relationship:

Insured Name: Insured SS#: Date of Birth:

Insurance Name: Policy#: Group#:

Insurance Address: City: State: Zip:

Insurance Phone Number: Relationship to insured:

SECONDARY COVERAGE

Insured Party: Self Spouse Other/ Relationship:

Insured Name: Insured SS#: Date of Birth:

Insurance Name: Policy#: Group#:

Insurance Address: City: State: Zip:

Insurance Phone Number: Relationship to insured:

Patient Information Form
ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE, UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE.

Financial Agreement

Services are rendered to the patient, not the insurance company. As a courtesy, our office will file your insurance if proper information is received.
You are responsible for co-pays, deductibles, non-covered services, co-insurances and items considered “not medically necessary” by your insurance company.
For unpaid claims over 45 days, it is your responsibility to follow up with your insurance and the balance due is considered due and payable.
It is you’re responsibility to notify our front desk staff of any insurance or address changes.
You will be responsible for any charges that occur if we are not notified.
Any debt incurred to collect a debt will be at the expense of the patient/responsible party.

Patient Authorization

I authorize College Station Med Plus to submit insurance claims using my signature on file below. I authorize the release of any medical information necessary in order to process this assignment on the claim. I authorize payment of medical benefits to be paid directly to College Station Med Plus for services describe on the claim form.

Patient Signature or Legal Representative Signature Date

I authorize College Station Med Plus to release any medical or billing information necessary, for treatment, payment or healthcare operations to the following family and or friends: (listed names and relationship)

Patient Signature or Legal Representative Signature Date

Patient Consent for E-Prescribing (Electronic Prescribing)

I have been made aware and understand this office may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my provider and my pharmacy. I have been informed and understand that my provider using the electronic prescribing system will be able to see information about medications I am already taking; including those prescribed by other providers. I give consent to my providers to see the protected health information.

I choose the pharmacy below as my primary pharmacy:

Pharmacy Name:

Address: City , TX. Zip

Preferred Lab:

Patient Printed Name

Patient Signature or Legal Representative Signature Date

Acknowledgement of Office Practices

This office utilizes a Physician Assistant and/or Nurse Practioner to provide efficient delivery of health care. He or she will assist with patient care always under direct physician supervision.

What are Physician Assistants and Nurse Practioners?

Physician Assistants and Nurse Practitioners practice medicine under the supervision of physians and surgeons. Physician Assistants and Nurse Practitioners are formally trained to provide diagnostic, therapeutic, and preventative healthcare services, as delegated by a physician. . Physician Assistants and Nurse Practitioners take medical histories, examine and treat patients, order and interpret laboratory tests and x-rays and make diagnoses; they also treat minor injuries by suturing, splinting, and casting. . Physician Assistants and Nurse Practitioners record progress notes, instruct and counsel patients, they also prescribe certain medication.

Authorization for Treatment

I have read the above information and understand that this office utilizes Physician Assistants and Nurse Practitioners as part of the continuing care, and I authorize treatment by the Physician Assistants and Nurse Practitioners.

Patient Printed Name

Patient Signature or Legal Representative Signature Date

Acknowledgement of Receipt of Notice of Privacy Practices

I, (print patient name), hereby acknowledge that I have received and reviewed the

Privacy Notice of College Station Med Plus.

Patient Signature or Legal Representative Signature Date

Print Name:

Relationship to Pt.:

Acknowledgment of No Show Policy

College Station Med Plus recognizes the need for a clear understanding between patient and physician regarding financial arrangements and standard office policies for your medical care. In order to provide you with the best and most efficient care, the following information is provided for you. If you have any question, please let us know before you sign this document.

Cancelling or Rescheduling an Appointment:

If you need to cancel or reschedule you appointment, you must notify our office at least 24 hours in advance of your already scheduled appointment. Failure to do so will be considered a “No Show” and result in a $25 fee for the first no show, $50 for the second and for each subsequent missed appointment thereafter. After the third missed appointment, you may be considered as a non-compliant patient and may be discharged from the practice. This fee is considered non-covered by insurance and you are responsible for the charge.

Patients with Medicaid or Medicaid Products:

Failure to appear for a scheduled appointment will be reported to Medicaid. Repeated no shows may result in loss of your Medicaid benefits.

15 Minute Policy:

If you are more than 15 minutes late for your appointment, you may be asked to reschedule.

I have read the above and agree to abide by this policy. I fully understand that failure to cancel and/or reschedule an appointment with less than a 24 hour notice, will be considered a No Show and as such will be subject to charge. Repeated No Shows may result in the termination of the Doctor-Patient relationship.

Patient Printed Name

Patient Signature or Legal Representative Signature Date

Welcome to College Station Med Plus

We are pleased to be your choice for your healthcare needs. Please take a moment to let us know how you were referred to our practice.

Today’s Date: ______

Printed Name: ______

* We respect your privacy and this information will only be used internally and will not be sold or distributed.

How did you hear about us?

 Another Physician

Please list the name of the physician

 Newspaper ______

 Magazine ______

 Radio

 Direct Mail Postcard

 Facebook

 Internet (Check one)

CollegeStationMedAssociates.com
CSMedCenter.com

 Yellow Pages

 Community Event

 Senior Circle Program

 Friend/Family Member

 Other ______

Please return this form to the receptionist along with your other paperwork. Thank you!