NEW PATIENT REGISTRATION FORM (PLEASE PRINT CLEARLY)
Name (Last, First, MI):______
Date of Birth: ______/_____/______Age ______Soc. Sec. #: ______/______/______
Marital Status: Married / Single / Widowed / Divorced Smoking: Current/Former
Race: Caucasian / African American / Asian / American Indian or Alaskan / Other ______
Home Address:______
City: ______State: ______Zip: ______
Cell #: ______Home #: ______Work #: ______
Email: ______
………………………………………………………………………………………………………………………………………………
Primary Care Physician:______Phone #:______
Employer:______Occupation:______
………………………………………………………………………………………………………………………………………………
EMERGENCY CONTACT INFORMATION
Name (Last, First, MI):______Relationship: ______
Address (if different) ______City:______State:_____ Zip: ______
Phone #: Cell / home / work ______Email: ______
………………………………………………………………………………………………………………………………………………
PHARMACY INFORMATION
Name: ______Address: ______City ______Pharmacy phone: ______
HOW DID YOU HEAR ABOUT US:
Referring Physician ______Friend: ______INTERNET (website): ______Other: ______
………………………………………………………………………………………………………………………………………………
BILLING POLICY:
Payment is required at time of service rendered and is the responsibility of the patient or guardian. Unpaid balances are due within 20 days of invoice. Payment is accepted in the form of cash, check or credit card. Balances more than 90 days may be charged 12% interest and collection attorney fees.
I, the patient named above, authorize Aziz Obgyn to apply for benefits on my behalf for covered services rendered. I request payment from my insurance company be made directly to the provider. I certify that the information I have reported regarding my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this related claim, to the above named billing agent and/or insurance company. I permit a copy of this authorization be used in place of the original. I authorize Aziz Obgyn to contact me by phone or email about appointments, billing and medical care. As the patient or guardian, I agree to the above terms and conditions
______
Signature of Patient or GuardianDate
New Patient Intake History (contd)
Name:______Birthdate: ______Age ______Today’s Date______
MEDICAL HISTORY (Please CIRCLE all that apply)
FibroidsEndometriosisOvarian CystOsteopenia/OsteoporosisThyroid Disease
DiabetesAnemiaKidney Disease Depression / AnxietySeizures / Epilepsy
Migraines High Blood PressureStroke Heart Attack
AsthmaGlaucomaGerdLiver DiseaseHepatitis/Jaundice
Cancer (Type) ______Other ______
SURGICAL HISTORY (Please CIRCLE all that apply)
C-Section #______HysterectomyOvarian Surgery : Removal One / Both Ovarian Cystectomy
Gall Bladder AppendixBowel SurgeryAnesthesia ComplicationTubal LigationLEEP
Other: ______
OB/GYN HISTORY (indicate number)
Pregnancies______Abortions/Miscarriages______Living Children______Vaginal ______C-Section______
Previous STD History VaginosisGenital Warts Chlamydia Herpes Trichomonas Gonorrhea Syphilis HPV
FAMILY HISTORY(Please CIRCLE all that apply)
Breast Cancer Ovarian CancerUterine Cancer Colon Cancer
Diabetes High Blood PressureHeart DiseaseStroke
Other: ______
SOCIAL HISTORY
Alcohol Yes / NoDrinks Per Day______Drinks / Week ______
Drug Use Yes / NoType______Times/Week______
Regular ExerciseYes / NoType______Times/Week______
Seat Belt Use Yes / No
Smoking Yes / NoPacks Per Day______Years______
ALLERGIES: none / other ______
CURRENT MEDICATIONS
______
______
LAST IMMUNIZATION (Please indicate year of last dose)Flu Shot: ______Dtap______Gardasil______
PERSONAL SAFETY
Has Anyone Close To You Ever Threatened To Hurt You?Yes / No
Has Anyone Ever Hit, Kicked, Choked, or Hurt You Physically?Yes / No
Has Anyone Including Your Partner Ever Forced You To Have Sex? Yes / No
Are You Afraid Of Your Partner?Yes / No
Patient Intake History
Name:______Birthdate: ______Age ______Phone: ______
REVIEW OF SYMPTOMS (Please CIRCLE any of the following conditions that apply to you now)
Constitutional Fever Weight Gain Weight Loss Weakness Fatigue
Head/Eyes:HeadacheChange in Vision
Ent: Change in Hearing Earaches Mouth Sores Sinus Problems
Cardiovascular: Chest Pain Palpitations Swelling Of Legs
Respiratory:Wheezing Chronic Cough Shortness of Breath Spitting Blood
GI : Nausea / Vomiting Dark or Bloody Stool Constipation / Diarrhea
Genitourinary: Abnormal Periods Painful IntercourseHot Flashes
Urination: Painful Urgency Frequency Incomplete Incontinence Blood
Musculoskeletal:Weakness Joint Pain/Stiffness Joint Swelling
Breast: Breast Pain Nipple Discharge Masses Rash Ulcers
Neurological Dizziness Seizures Numbness Trouble Walking
Psychiatric: DepressionFrequent CryingSuicide/Homicide ideation
Endocrine: Dry Skin Abnormal Thirst Hematologic/Lymphatic: Bruising Enlarged Lymph Nodes
Allergic/Immunologic Allergies Drugs
Other______
Last Menstrual Period : ______Current Birth Control: ______
Date of Last PAP : ______Previous ABNORMAL PAP? Yes / No
Date of Last Mammogram: ______Date of Last Dexa:______
Any Updates in your
Medical History ______
Surgical History______
Pregnancy History ______
Medications ______
SIGNATURE OF PATIENT______DATE______
USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION AGREEMENT
This disclosure contains information regarding the privacy of your personal healthcare information. Please read it carefully before signing. Aziz Obgyn will not condition treatment by your failure to sign this disclosure.
By signing this disclosure I acknowledge that Aziz Obgyn may use or disclose my medical information for the purpose of my treatment or obtaining payment for services rendered. I am aware that Aziz Obgyn may disclose my medical information to a Business Associate for the same reasons, and that the Business Associate will be bound by all appropriate legal restrictions.
Further, by signing this document I acknowledge that I have been provided a copy of and have read the Notice of Privacy Practices containing a complete description of my rights, and the permitted uses and disclosure, under HIPAA.
We may use your information to contact you, send newsletters or other information. We may call you re: appointment reminders and leave message on the machine or person answering the phone. In an emergency, we may disclose your health information to a family member or another person responsible for your care. We may release some or all your health information when required by law. If this practice is sold, your information will become the property of the new owner.
Acknowledged and agreed by:
Patient (print name): ______or Guardian: ______
Signature: ______Date: ______
------
The Federal Government now restricts this office and Aziz Obgyn from discussing your health information and condition with other family members or person unless you specifically give your written permission.
By my signature below, I grant Aziz Obgyn permission to discuss my protected medical information with the following individuals:
Name ______Relationship ______
Name ______Relationship ______
Signature of Patient: ______Date ______
Please list daytime telephone ______