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
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
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 INFORMATIONInsurance 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 FormALL 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
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!