Rheumatology Associates

RHEUMATOLOGY ASSOCIATES

OF SOUTH FLORIDA

PATIENT INFORMATION

PLEASE PRINT CLEARLYDATE ______

Patients Name ______Age ______Sex ______Date of Birth ______

CIRCLE ONE Single,Married, OtherPatients Social Security Number ______

Address ______Apt______

(LOCAL ADDRESS)

City ______State ______Zip Code ______

Telephone Number ______Cell Number ______

Work Number ______Email ______

Primary Emergency Contact Person ______Phone # ______

IF YOU’RE A SEASONAL RESIDENT AND YOU HAVE A NORTHERN ADDRESS, PLEASE FILL IN BELOW

Address ______Apt ______

(NORTHERN ADDRESS)

City ______State ______Zip Code ______

Telephone Number ______

Please Circle Below

Preferred Language: English, Spanish, French, German, Japanese, Mandarin, Russian, Refused to Report

Race: White, African American, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Island, Other, Refuse to Report

Ethnicity: Hispanic, Non-Hispanic, Refuse to Report

Smoking Status: Current-every day, Current-some days, Former Smoker or Never

Employed By ______Occupation ______

Spouses Name ______Spouses Date of Birth ______

Spouses Social Security Number ______(Applicable if secondary insurance in under spouses name)

Referred to the Practice by ______Primary Doctor ______

Local Pharmacy Name, Phone # or Address and City

1.______

2. ______

Mail Order Pharmacy Name and Phone # or Address and Patient ID # 3.______

Charges for medical services are due and payable at time services are rendered. We will file your insurance if the doctor you are seeing is a provider of your plan. All balances not paid by your insurance carrier are your responsibility to pay.

LIFETIME AUTHORIZATION

I certify that the information given by me, in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration intermediaries or carrier of any information needed for this or a related medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.

I request that, the authorization also apply to all other insurances.

Name ______

Signature ______Date ______

RHEUMATOLOGY ASSOCIATES

OF SOUTH FLORIDA

INTAKE FORM

PLEASE PRINT CLEARLY

Patients Name ______Date of Birth ______

What is your main reason for today’s visit ______

Briefly describe your symptoms ______

List all other physicians you have seen for this problem ______

______

Diagnosis given ______

PAST MEDICAL HISTORY

Do you or have you had (circle all that apply and explain)

Cancer ______Thyroid problems ______

Diabetes ______High blood pressure ______

Stroke ______Heart problems ______

Kidney disease ______Lung problems ______

Bowel problems ______Ulcers ______

Eye problems ______Skin problems ______

Osteoarthritis ______Rheumatoid Arthritis ______

PMR ______Lupus ______

Temporal Arteritis ______Other ______

PAST SURGICAL HISTORY

Please list all your operations and dates

______Date ______

RHEUMATOLOGY ASSOCIATES

OF SOUTH FLORIDA

Patients Name ______Date of Birth ______

MEDICATION AND HISTORY

FAMILY HISTORY

FATHER Alive or Deceased Age ______Illness______

MOTHER Alive or Deceased Age ______Illness______

BROTHERS/SISTERS Alive or Deceased Age ______Illness’s______

CHILDREN Alive or Deceased Age ______Illness______

OCCUPATIONAL / SOCIAL HISTORY

Who do you live with ______

If you presently smoke, how many packs per day______

If you were a former smoker, when did you quit ______

Do you drink alcohol NO or YES Daily ______Occasionally ______How many drinks per week ______

Do you exercise regularly NO or YES What type ______

MEDICATIONS

Please list all the medications, including vitamins and supplements and how you take them

Medication MG/UnitsDosage/Frequency

______

List any medications you have taken in the past for your present condition

______

Were any helpful NO or YES Which one ______

ALLERGIES TO MEDICATIONS______