Maryville Physician Services, Llc

MARYVILLE PHYSICIAN SERVICES, LLC

Anita Sandhu, M.D.

PATIENT REGISTRATION

Patient Last Name ______First Name ______Middle Initial ______

Address ______City______State ______Zip ______

Home Phone ______Work Phone ______Cell Phone ______

Email address ______Fax ______

SS# ______Date of Birth ______Sex: female, male

Marital Status ______

Employer Name ______Phone ______

Employer Address ______City ______State ______Zip ______

Which is preferred phone number to call? ___Home, ___Work, ___Cell.

Is it okay to leave voice mail messages with private health information? ___Yes, ___No

How would you like to receive lab results or notice of other reports? ___Fax, ___Email,___Standard Mail

INSURANCE INFORMATION

Primary Insurance

Insurance Name ______Policy # ______Phone ______

Name of Insured ______Relationship ______

SS# ______Date of Birth ______

Employer Name ______Phone ______

Employer Address ______City ______State ______Zip ______

Secondary Insurance

Insurance Name ______Policy # ______Phone ______

Name of Insured ______Relationship ______

SS# ______Date of Birth ______

Employer Name ______Phone ______

Employer Address ______City ______State ______Zip ______

Referring Physician Name ______Phone ______

PCP Name ______Phone ______

Emergency Contact ______Phone ______

I hereby authorize the providers of Maryville Physician Services, LLC, AnitaSandhu, M.D. to treat the patient identified above. I acknowledge that I am responsible to pay allcharges for all treatments administered by the physician to the patient. I understand that insurance may not pay for all charges and I understand that Iam obligated to pay for all charges not paid by insurance. I also agree to pay reasonable attorney fees if my account is turned over to an attorney orcollection agency.Assignment and Release: I hereby authorize my insurance benefits to be paid directly to the physician and understand I am financially responsiblefor non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims.I acknowledge receipt of the Notice of Privacy Practices for Maryville Physician Services, LLC, AnitaSandhu, M.D.

Signature of Patient / Authorized Person______Date ______

MARYVILLE PHYHSICIAN SERVICES, LLC

ANITA SANDHU, M.D.

Date______Patient Name:______

Do you have an advanced directive?______

Medication History: Please list medications , dosage, frequency and problem, you are CURRENTLY taking: Continue on back if necessary: BRING MEDICATIONS WITH YOU IF YOU DO NOT COMPLETE THIS

Medication Name Dosage How Often For what

______

______

______

______

Do you take any non-prescription medications, health foods, vitamins?______

______

______

Current Pharmacy:______

Name Phone Number Location

ALLERGIES: List any medications or other substances that you are ALLERGIC to:

ALLERY REACTION

______

______

______

______

______

Medical History: Please circle all past or present medical problems and/or symptoms:

ADD/ADHD Depression Osteoporosis

Alcoholism Diabetes Psychiatric Problems

Alzheimer's Disease Drug or Substance Abuse Prostate Disease

Anemia Glaucoma Renal Disease

Anxiety Hearing Loss Stroke

Arthritis Shortness of Breath

Asthma Heart Disease Seizure Disorder

Atrial Fibrillation High Blood Pressure Thyroid Disease

Back Pain Hyperlipidemia Visual Loss

Blood Disorder Hypercalcemia Ulcers

Cancer Hepatitis

Carotid Artery Disease

Cataracts Liver Disease

Congestive Heart Failure Lung Disease

COpD Migraines

Chest Pain Obesity

Have you ever been in the hospital of had surgery? Yes or NO; If yes, please list type of surgery and date of surgery, use the back if more space is needed.

______

______

______

______

FAMILY HISTORY: (IMMEDIATE) F=Father,M= Mother,B= Brothers, S=Sisters, G=Grandparents)

Alive: Age Medical Problems or Cause of Death

Father:______

Mother:______

Other:______

Other:______

Identify by F,(Father) M,(Mother) B,(Brother) S(Sister) or G ( Grand Parents Please identify if Maternal or Paternal Grand Mother or Grand Father) if immediate family member has or had any of the following:

ADD/ADHD ___ Depression ___ Osteoporosis ___

Alcoholism ___ Diabetes ___ Psychiatric Problems __

Alzheimer's Disease ___ Drug or Substance Abuse ___ Prostate Disease ___

Anemia ___ Glaucoma ___ Renal Disease ___

Anxiety ___ Hearing Loss ___ Stroke ___

Arthritis __ Shortness of Breath __

Asthma ___ Heart Disease ___ Seizure Disorder ___

Atrial Fibrillation ___ High Blood Pressure ___ Thyroid Disease ___

Back Pain ___ Hyperlipidemia ___ Visual Loss ____

Blood Disorder ___ Hypercalcemia ___ Ulcers ____

Cancer (What type) ___ Hepatitis ___

Carotid Artery Disease ___

Cataracts ___ Liver Disease ___

Congestive Heart Failure ___ Lung Disease ___

COpD ___ Migraines ___

Chest Pain ___ Obesity ___

SOCIAL HISTORY:

Do you use tobacco? yes or no. Cigarettes ______Cigar ______Chew ______

How many packs? ______How many years? ______

Have you tried to quit? ______How long have you quit?______

Do you drink alcohol? yes or no, If yes, how much ______

and how often?______

Are you watching your diet or following any strict dietary guidelines?______

______
______

ADDITIONAL DEMOGRAPHIC INFORMATION

TO ALL PATIENTS:

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) recommend we ask patients to provide the following (optional) information.

NAME______DATE OF BIRTH______

Race - Please check the appropriate answer:

Alaska Native ______

American Indian or Alaska Native ______

Asian ______

Black or African American ______

Greek ______

Hispanic______

Latino______

Native Hawaiian or Other Pacific Islander ______

White______

Other______

please specify

ETHNICITY

Hispanic or Latino ______

Not Hispanic or Latino ______

PREFERRED SPOKEN LANGUAGE:

English: ______

Other: ______

please specify

PREFERRED METHOD OF COMMUNICATION - PLEASE CHECK ONE

Phone _____

Mail _____ Secure Messaging ______

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