MARIO MAGCALAS, M.D., P.A.

INTERNAL MEDICINE PULMONARY DISEASE AND CRITICAL CARE

www.mariomagcalasmdpa.com

PATIENT INFORMATION
Last Name: / First Name: / Middle Initial:
Date of Birth: / / Age: / Sex:
Male Female / Marital Status:
Single Married Divorced
Widowed Legally Separated
Race:
American Indian Native American Alaskan Native
Asian Black Caucasian
Pacific Islander
Other Declined / Ethnicity:
Hispanic
Non-hispanic
Declined / Language:
English
Spanish
Other
(Other):
Home Phone: ( ) - / Cell Phone: ( ) - / Email:
Address: / City: / State: / Zip Code:
Social Security: - - / Occupation:
Employer: / Work Phone: ( ) - x
Spouse’s/Guardian’s Name: / Phone: ( ) -
INSURANCE INFORMATION
(If you have an HMO, please bring referral for each visit. Faxed-referrals are not reliable)
Primary Insurance: / Policy Number:
Subscriber: / Group Number:
Insurance Address: / City: / State: / Zip Code:
Secondary Insurance: / Policy Number:
Primary Care Physician: / Physician’s Phone: () -
Were you referred by your Primary Care Physician: Yes No
Do you need a copy of your progress report to go to your Primary Care Physician: Yes No
Emergency Contact: / Emergency Contact’s Phone: ( ) -
Reason why you are being referred to this office: ______
______.
I directly assign all medical benefits to be paid to Mario Magcalas, MD, PA and I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement is valid as original.
Patient’s Signature: ______/ Date: /
Please complete the following questions. This is a confidential record and the information contained here will not be released without your permission. Please bring the name and addresses of all former physicians or hospitals from whom we can obtain pertinent old medical records. Also bring all medications, including vitamins and those you have purchased without a prescription.
Last Name: / First Name: / Middle Initial:
Date of Birth: / / Age: / Weight: lbs / Height: ft in
List latest date for the following immunizations: / Tetanus Shot:
/ / / Pneumovax:
/ / / Flu Shot:
/ /
If patient is a minor, are all immunizations current: Yes No
Do you have a copy of the shot records: Yes No
Please list all medications you take on a routine basis: None
Please list all allergies to medications or foods: None
Do you smoke: Yes No / If Yes, how much per day: stick / If Yes, for how long: mm yy
Do you consume any alcoholic beverages: Yes No
Do you drink coffee:
Yes No / Do you drink Tea:
Yes No / Do you drink caffeinated beverages:
Yes No
Family History: / Father’s Side: / Mother’s Side:
• Asthma
• Cancer of ______
• Chronic Lung Problems
• Diabetes
• Heart Attack
• High Blood Pressure
• Stroke
Social History: / Occupation:
Current Living Arrangement: / Own Home / Rent / Senior Apartment / Adult Foster Care
How would you rate your overall health: / Excellent / Good / Average / Fair / Poor
Please complete the following questions. This is a confidential record and the information contained here will not be released without your permission. Please bring the name and addresses of all former physicians or hospitals from whom we can obtain pertinent old medical records. Also bring all medications, including vitamins and those you have purchased without a prescription.
Last Name: / First Name: / Middle Initial:
Date of Birth: / / / Date: / /
PAST MEDICAL HISTORY:
Attention Deficit Disorder / Coronary Artery Disease / Hypertension Nos
Allergic Rhinitis Nos / COPD/Emphysema / Hypthyroidism
Alzheimer/Dementia / Crohn’s Disease / Irritable Bowel Syndrome
Anemia / CVA / Interstitial Lung Disease
Anxiety / Depression / Kidney Stone
Arthritis, Degenerative / Diverticulosis of Colon / Lung Nodule
Arthritis, Rheumatoid / DVT / Migraine
Asthma Nos / Type II Diabetes / Mitral Valve Prolapse
Atrial Fibrillation / Eczema / Obstructive Sleep Apnea
Back Pain / Endometriosis / Osteoporosis
Benign Prostatic Hyperplasia / Erectile Dysfunction / Osteopenia
Barretts Esophagus / Fibromyalgia / Peptic Ulcer Disease
Bipolar Disorder Nos / Fibroids / Peripheral Vascular Disease Nos
Cancer of ______/ Gout / Pneumonia
Carpal Tunnel Syndrome / Hepatitis A / Polycystic Ovarian Syndrome
Cardiac Murmur / Hepatitis B / Pulmonary Embolism
Chronic Bronchitis / Hepatitis C / Pulmonary Fibrosis
Chronic Kidney Disease Nos / Gastroesophageal Reflux Disease / Pulmonary Hypertension
Chronic Pain Syndrome / Hemorrhoids / Restless Leg Syndrome
Chronic Sinusitis Nos / HIV/AIDS / Tobacco Use Disorder
Colitis / Hiatal Hernia / Tuberculosis
Colon Polyps / History of Drug Abuse / Ulcerative Colitis
Congestive Heart Failure / Hyperlipidemia
PAST SURGICAL HISTORY:
Angiplasty (Heart Stent) / Colonoscopy / Mastectomy (Removal of Breast)
Ankle Surgery / EGD / Nasal Septum Surgery
Appendectomy / Gastric Bypass / Shoulder Surgery
Blood Transfusion / Hernia ______/ Sinus Surgery
CABG (Heart Bypass Surgery) / Hysterectomy (Removal of Uterus) / Splenectomy (Removal of Spleen)
Cardiac Catheterization / Joint Replacement / Tonsillectomy
Cataract Surgery / Knee Surgery / Tonsillectomy/Adenoidectomy
Cesarian Section / Lumpectomy (Removal of Lump on Breast) / TAH/BSO (Removal of Uterus & Ovaries)
Cholecystectomy (Gallbladder Removal) / Lung Surgery / Thyroidectomy
Last Name: / First Name: / Middle Initial:
Date of Birth: / / / Date: / /
REVIEW OF SYSTEMS:
(PLEASE MARK ANY SYMPTOMS)
CONS: / Fever / Chills / Night Sweats / Weight Loss / Weight Gain
Lack of Appetite / Malaise / Fatigue
EYES: / Redness / Pain / Discharge / Visual Loss / Blurred Vision
Double Vision
ENT: / Sore Throat / Hoarse / Nose Bleed / Hearing Loss / Ear Pain
Nasal Congestion / Sinus Pain / Sneezing
CV: / Chest Pain / Palpitations / Rapid/Slow Heart Beat / Orthopnea / Diaphoresis
Swelling of Legs / Shortness of
Breath during Sleep
RESP: / Wheezing / Productive
Cough / Dry Cough / Coughing of
Blood / Chest Pain with
Breathing
Shortness of
Breath at Rest / Shortness of
Breath at Exertion
GI: / Abdominal Pain / Nausea / Vomiting / Diarrhea / Constipation
Bleeding / Bloating / Reflux / Difficult Swallowing
GU: / Painful Urination / Urgency / Hesitancy / Blood in Urine / Incontinence
Flank Pain
MUSC: / Muscle Pain / Joint Pain / Neck/Back Pain / Tendonitis / Calf Pain
Bursitis
SKIN: / Rash / Hives / Redness / Bruising / Laceration
Abrasion
NEURO: / Headache / Seizure / Numbness / Dizziness / Memory Loss
Slurred Speech / Loss of
Consciousness
PSYCH: / Depression / Hallucinations / Suicidal/Homicidal / Delusions / Anxiety
HEME: / Bleeding / Bruising / Clotting
ALLERGY: / Hives / Running Nose / Stuffy Nose / Cough / Recurrent Infections
Itchy or Watery
Eyes
ENDO: / Frequent Urination / Frequent Thirsty / Frequent Hunger / Thyroid Problems
SLEEP: / Snoring / Restless Leg / Talks/Walks
during Sleep / Wakes up tired in
Morning / Excessive Daytime
Sleepiness
Stop Breathing
during Sleep / Frequent Arousals
during Sleep / Poor Sleep

Patient Denies All

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM
I, ______, have received a copy of MARIO MAGCALAS, M.D., P.A. Notice of Privacy Practices.
Patient’s Signature: ______/ Date: / /
MEDICAL RECORDS RELEASE
I hereby authorize to release my medical records to:
Mario Magcalas, M.D., P.A.
10794 Pines Blvd, Ste 205
Pembroke Pines, FL 33026
Tel: (954) 538-8543 / (954) 441-5063
Fax: (954)431-8153
Email:
Name of Facility:
Address: / City: / State: / Zip Code:
Telephone: / ( ) -
Fax Number: / ( ) -
Patient:
Last Name: / First Name: / Middle Initial:
Date of Birth: / / / Social Security: - -
Home Phone: ( ) - / Cell Phone: ( ) - / Email:
Address: / City: / State: / Zip Code:
Patient’s Signature: ______/ Date: / /

BOULEVARD PROFESSIONAL CENTRE I ● 10794 PINES BOULEVARD, SUITE 205, PEMBROKE PINES, FLORIDA 33026 ● TEL.: (954) 538-8543 / (954) 441-5063 ● FAX: (954) 431-8153

BY: NOA – NOVEMBER 2016