WELCOMETOOUROFFICE!!Thank youforselectingourpractice.Inorder toprovidethe best medical care and a great experience when you visit us please read on. If you haveanyother questions, feel free to call us at (301)663-3836.
*************WHAT TO BRING WITHYOU*************
MEDICALHISTORYFORM(ifincludedinthispacket)Fillingthisoutathomewillgiveyoutimetoconsiderthesequestionsinsteadofrushingtocompleteitwhilesittinginouroffice.
DRIVER’S LICENSE OR OTHER PICTURE ID This is to help prevent identity theft
INSURANCECARDANDCOPAYTheamountofthecopayisusuallyprintedonyourinsurancecard.Youwillneedtopayyourcopaywhenyouarrivewhichyoucanpaywithcash,check, orVisa/MasterCard
INSURANCEREFERRALIfrequired,yourprimarycaredoctorwillprovidethistoyou.Check with your insurance company. Without it your insurance may not pay for your visit.
MEDICAL RECORDS Your other doctors will provide this for you when you ask.
BRING THYROID ULTRASOUND OR SCAN FILMS to yourappointment.
Ifyou areseeingoneofourEndocrinologist, Dr.Hakim orJinhui Yuan, PA-Cweaskyouto bringtheactualfilmsforreview.Pleasecontacttheradiologydepartmentwherethetestwasperformed to schedule a pick uptime.
PRESCRIPTIONSBringtheprescriptionbottlessoyourdoctorknowsexactlywhatyouarecurrently taking and thedosage.
***********HELPFULTIPSFROM OUROFFICE***********
RUNNINGLATE?Weunderstandthatcircumstancescansometimespreventyoufromarrivingontime.Ifthishappens,wewilltryourverybesttoaccommodateyouwithintheschedule.Ifweareunable to see you or you cannot wait, we will be happy to reschedule your appointment.
CANCELLATIONIfyouneedtocancelorrescheduleanappointmentpleasecallourofficeatleast24hoursbeforeyourappointment.Brokenappointmentsrepresentacosttous,andtootherpatientswhocouldhavebeenseeninthetimesetasideforyou.Wereservetherighttochargeformissedorlate-canceledappointments.Excessiveabuseofscheduledappointmentsmayresultindischargefromthepractice.
BLOOD PRESSURE CHECKS, ALLERGY INJECTIONS, FLU SHOTS You may come
into our office without an appointment between 10 am and 12 pm or between 2 pm and 4 pm, onTuesdays,WednesdaysorThursdays.Theremightbeawaitbutthenursewillseeyouassoonaspossible.Ifyoucannotcomeduringthesetimes,pleasecallourofficesowecanarrangeatimethatismore convenient foryou.
PAYMENTIfyouhaveanyquestionsaboutwhatinsurancesweaccept,oraboutpaymentofyourdeductible or copay please call our billing office at 301-663-3836 and select prompt 2.
PRESCRIPTIONREFILLSIfyouneedtorefillyourmedicationthatwehaveprescribed,callyour pharmacy. They will contact us for you to obtain the refillauthorization.
HOURSTheofficeisopenMondaythroughFridayfrom8:00amto5:00pm.Youcanreachusbyphonebetween8:30amand4:00pm.Ourphonesareoffbetween1:00pmand1:30pmsoouroperatorscan take alunch.
ANY OTHER QUESTIONS,CALL(301)663-3836
******************DIRECTIONS*******************
DirectionstoOurFrederickOfficeFrom270,70or340,take15NorthtowardsGettysburg.TaketheMotterAvenueExit.BeartotherightontoOpossumtownPike. Gooverthebridge.At the third light, turn right onto Thomas Johnson Drive. Go approximately 1 mile. Our officeis locatedofthe leftside at65ThomasJohnsonDrive. WeareinthesecondbuildinginSuiteC.
From Thurmont orEmmitsburg:Directly from route 15 (south) you will take theHaywardRoadExit.Atthe yieldsignbeartotherightandcontinue onHaywardRoad.TakeyourfirstleftontoThomasJohnsonDrive.Ourofficeislocated ontherightsideat65ThomasJohnsonDrive. We are the second building in suiteC.
PATIENTSNAME:
(LAST)(FIRST)(M.I.)
BIRTHDATE://AGE:SEX:SOCIAL SECURITY#(SSN):
ADDRESS:
(STREET)(CITY)(STATE)(ZIPCODE)
HOMEPHONE:WORKPHONE:CELLPHONE:
EMAILADDRESS:
MARITALSTATUS:SINGLEMARRIEDDIVORCEDWIDOWEDPATIENTSEMPLOYER: POSITION:
EMPLOYERADDRESS:
IF PATIENT IS A MINOR, PARENT OR GUARDIAN’S NAME:
PERSON FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT:
PRIMARY INSURANCE COMPANYNAME: SUBSCRIBER’SNAME: SUBSCRIBER’S BIRTHDATE: SUBSCRIBER’SSSN: INSURANCE COMPANYADDRESS: COPAY: POLICYNUMBER: GROUPNUMBER:
SECONDARY INSURANCE COMPANYNAME: SUBSCRIBER’SNAME: SUBSCRIBER’S BIRTHDATE: SUBSCRIBER’SSSN: INSURANCE COMPANYADDRESS: COPAY: POLICYNUMBER: GROUPNUMBER:
NEXT OFKIN:PHONENUMBER ADDRESS:
IN CASE OF EMERGENCY CONTACT:PHONENUMBER:
IF YOU ARE SEEING DR. HAKIM OR JINHUI YUAN, PA-C, PLEASE LIST YOUR PRIMARY CAREDR
NAME: PHONENUMBER:
IAUTHORIZETHEABOVEMEDICALPRACTICETORELEASEANYMEDICALINFORMATIONNECESSARYTOPROCESSMYCLAIMS.IUNDERSTANDTHATIAMFINANCIALLYRESPONSIBLEFORALLFEESFROMSERVICESPROVIDED,INCLUDINGTHEBALANCEREMAININGAFTERPAYMENTOFPOSSIBLEINSURANCEBENEFITSANDANYCOSTSINCURREDBYTHEPHYSICIAN(S)INORDERTOCOLLECTSUCHFEES.
SIGNED:DATE:
PATIENT(ORPARENT’SSIGNATUREIFPATIENTISAMINOR)
NAME:AGE:
SOMEOFTHEQUESTIONSMAYNOTAPPLYTOYOU.PLEASELEAVETHEMBLANK.IFYOUDONOTUNDERSTANDANYQUESTION,PLEASEMARKTHEMWITHAN‘A’.
REASONFORYOURVISITORYOURCONCERNSORQUESTIONS:
1.
2.
3.
PASTORPRESENTMEDICALPROBLEMS(ANYTIMEINLIFE)
DISEASEYESORNODISEASEYESORNODISEASEYESORNO
SINUSINFECTION / ASTHMA / HAYFEVERPHEUMONIA / BRONCHITIS / EMPHYSEMA
CORONARYARTERYDIS / HIGHBLOODPRESSURE / STROKE ORMINI
HEARTMURMUR / HEARTATTACK / HEARTFAILURE
BLOOD CLOTS(LEG/LUNG) / MITRALVALVEPROLAPSE / IRREGULARHEARTBEATS
HIATALHERNIA / ANEMIA / STOMACHULCERS
HEMORRHOIDS / ACIDREFLUX / DIVERTICULOSIS
DIABETES / BOWELORCOLONPOLYP / HEPATITIS/LIVERDISEASE
HIGH CHOLESTEROL / GALLSTONES / KIDNEYSTONES
SKINCANCER/MOLES / FREQUENTURINEINFECTION / THYROIDDISEASE
CATARACTS / SEXUALLY TRANSMITTEDDIS / FRACTUREDBONES
DEMENTIA / OSTEOPOROSIS / ARTHRITIS
PANICATTACKS / GLAUCOMA / HEARINGPROBLEMS
DEPRESSION / ANXIETYDISORDER / ANYCANCER
ANYOTHERPROBLEMS:
PASTSURGERIES:(PLEASEMENTIONALLMAJORANDMINORSURGERIESORPROCEDURES.EX.BREASTBIOPSY,BACKORJOINTSURGERY,HYSTERECTOMY,TONSILSREMOVED,APPENDIXREMOVED,ETC.)
1.2.3.
4.5.6.
7.8.9.
HAVEYOUEVERHADABLOODTRANSFUSIONATANYTIME?IFYES,WHEN?WHY?
IMMUNIZATIONS:(WHENDIDYOUHAVETHELASTSHOT?IFYOUDONOTREMEMBER,PLEASEWRITE‘UNKNOWN’.IFYOUHAVENEVERHADIT,PLEASEWRITE‘NEVER’.)
TETANUS: / yearsago / FLU: / yearsagoPNEUMONIA: / yearsago / MMR: / yearsago
HEPATITISB: / yearsago / PPD: / yearsago
AREYOUATANYRISKOFTICKBITES?YESNO
HAVEYOUHADTICKBITESATANYTIMEINTHEPAST?YESNO
ALLERGIES:(FOODORDRUGS,PLEASEMENTIONTYPEOFREACTIONTOEACHALLERGY)
MEDICINES:(PLEASELISTALLMEDICATIONYOUARECURRENTLYTAKING)
Please bring all current Medication Bottles to yourvisit
Name:Date ofBirth:
HEALTH MAINTENANCE:(PLEASEMENTIONWHENYOURLASTEXAMORTESTWASDONE)
MALE:
SIGMOIDOSCOPY/COLONOSCOPY(AFTER50YEARSOFAGE)CHOLESTEROLLEVELCHECKED(AFTER25YEARSOFAGE)PROSTATE EXAM WITH FINGER (AFTER 50 YEARS OF AGE)
PSA SCREENING (TESTING FOR PROSTATE CANCER, AFTER 50 YEARS OF AGE)
FEMALE:
SIGMOIDOSCOPY/COLONOSCOPY(AFTER50YEARSOFAGE)CHOLESTEROLLEVELCHECKED(AFTER25YEARSOFAGE)PELVIC EXAM (AFTER 20 YEARS OF AGE)
BREASTEXAMBYDOCTOR(AFTER30YEARSOFAGE)PAP SMEAR (AFTER 20 YEARS OF AGE)
MAMMOGRAM (AFTER 40 YEARS OF AGE)BONE DENSITY SCAN (AFTER MENOPAUSE)
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
YEARSAGO
OBSTETRICSANDGYNOCOLOGYHISTORY:(IFTHEQUESTIONDOESNOTAPPLYTOYOU,PLEASELEAVEITBLANK)
HOW MANY TIMES HAVE YOU BEEN PREGNANT?
DIDYOUHAVEANYABORTIONSORMISCARRIAGES?ATWHATAGEDIDYOUHAVEYOURFIRSTPERIOD?DO YOU USE BIRTH CONTROL PILLS?
ARE YOUR PERIODS REGULAR?
AREYOURPERIODSVERYPAINFUL?ARE YOUR PERIODS HEAVY?
DO YOU HAVE HOT FLASHES?
FAMILYHISTORY:(MAINLYPARENTS,GRANDPARENTS,SIBLINGSANDCHILDREN)
PLEASEMENTIONANYMEDICALPROBLEMSYOURFAMILYMEMBERSPRESENTLYHAVEORHAVEHADINTHEPAST.ALSOMENTIONIFSOMEONEHASDIEDANDTHECAUSEOFTHEIRDEATH(IFKNOWN).
GRANDFATHER:GRANDMOTHER:FATHER: MOTHER: BROTHER: SISTER: CHILDREN:
DISEASEWHO?ASTHMA STROKE DIABETES DEPRESSION ANEMIA PROSTATECANCER OVARYCANCER
DISEASEWHO?CAD HIGH BLOODPRESSURE THYROIDDISEASE PSYCH.HISTORY COLON/BOWELCANCER BREASTCANCER LUNGCANCER
DISEASEWHO?HEARTATTACK HIGHCOLESTEROL OSTEOPOROSIS TUBERCOLOSIS SKINCANCER UTERINECANCER ANY OTHERCANCER:
ANY OTHERHISTORY:
SOCIALHISTORY:
ARE YOUSINGLE?MARRIED?DIVORCED?WIDOWED? HOW MANY CHILDREN DO YOU HAVE?
DO ANY LIVE NEARBY? (PLEASE WRITE HIS/HERNAME) DO YOU CURRENTLY WORK? IF YES, WHAT KIND OF WORK DO YOU DO? HAVE YOU EVER SMOKED? IF YES, HOW MUCH DO/DID YOU SMOKE, AND HOW LONG? DO YOU SMOKENOW?
DOYOUUSETOBACCOINANYOTHERFORM?(EXAMPLE:CHEWINGTOBACCO,CIGARS,ETC.) HAVE YOU EVER USED HEROIN, COCAINE OR MARIUANA LIKE DRUGS? DO YOU CURRENTLY USE ALCOHOL? IF YES, HOW MUCH?
DO YOU FOLLOW A SPECIALDIET? DO YOU EXERCISE: IF YES, WHAT KIND AND HOWFREQUENTLY? HAVE YOU EVER BEEN PHYSICALLY OR EMOTIONALLY ABUSED? DO YOU HAVE A LIVING WILL?