Wabash General Hospital

General Surgery

1430 College Drive, Suite B

Mt. Carmel, IL 62863

New Patient Information

Today's Date -

Full Name -

Date of Birth - Age - Gender -

Marital Status - Race -

SSN -

Phone Number -

Email Address -

Address/City/State -

Employer/Address -

Emergency Contact Name/Number -

Emergency Contact Relationship/Date of Birth -

Referring Physician -

Primary Physician -

Insurance Information

Primary Insurance -

Primary Holder Name/DOB/SSN -

Policy #/ Group # -

Secondary Insurance -

Secondary Holder Name/DOB/SSN -

Policy #/ Group # -

I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and or surgical benefits to include major medical benefits to which I am entitled to WGH photocopy is considered valid. I certify the above information is correct to the best of my knowledge. I also understand that I am financially responsible for all charges.

Signature: Date:

Guarantor- only complete if you are under 18 or have a POA (person responsible for bill)

Guarantor Name-

Date of Birth- Age- Gender-

Relationship to Patient- SSN-

Phone Number- Work Number-

Home Address/City/State/Zip-

Employer/Employer Address-

Signature: Date:

Privacy Questionnaire and Policy Disclosure Statement

Please note: If this section is not completed, we are unable to discuss these issues or release information to anybody other than you (and those entities allowed by law).

1.  List the family member(s) or other person(s) that we may inform of your medical condition, treatments, appointments, and account information.

Name: Phone Number:

Name: Phone Number:
Name: Phone Number:

2.  Please print the address of where you would like correspondence from our office to be sent if other than your home address.

3.  Can confidential messages be left on your home telephone answering machines? Yes/No

I ______(the patient/ patient’s legal representative) hereby grant permission to Richard F. Oppeltz, M.D. to perform such examinations and medical and therapeutic procedures professionally deemed necessary or advisable for the patient’s diagnosis and treatment.

I verify that I have been offered and/or received a copy of Wabash General Surgeon’s Notice of Privacy Practices (NPP) in regards to the HIPAA Privacy Act.

Patient Name Printed: ______Date: ______

Patient Signature: ______

Financial Agreement and Authorization for Treatment

I understand that I am seeking treatment from Wabash General Hospital’s Provider-Based Clinic. I am aware that there may be separate charges for the hospital and physician. Depending on the services provided, additional out-of-pocket expenses may be incurred. Patients are advised to review their insurance benefits or contact their insurance provider to determine what their policy will cover.

Wabash General Hospital General Surgery Clinic will complete forms at the patient’s request. A $15 fee will be charged for each set of forms, payment is due prior to completion.

Patient Name Printed: Date:

Patient Signature:

Date:

Dear ,

We look forward to seeing you on .

In an effort to expedite your time and ours, we pre-register our patients prior to their visit. Please complete the forms that are included with this letter. You may mail them, fax them or bring them in to our office but we need them back at least two (2) days prior to your appointment. Incomplete papers or papers not returned prior to appointment may require that we reschedule your appointment.

Please note that directions to our office are on the back of this letter.

At the time of each of your appointments, please come prepared with the following items; your insurance card, a photo ID and a list of your current medications including the name, strength, and directions for taking them. This is required at each visit.

If you cannot keep your appointment, please call us one business day ahead so that another patient can be scheduled. If you have any questions or need assistance please call our office at 618-263-6190. Our fax number is 618-262-7351.

Respectfully,

Patient Account Representative

If you are coming from Rt. 1, North: Turn right on 13th street. Go two blocks to college drive. Turn right on college drive. Continue on college drive. We are located in the curved front brick building that also has Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Rt. 1, South: Turn left on market street. Continue until Market Street becomes college drive. Continue on college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Indiana HWY 64: IN-64 becomes IL- 15/South walnut street. Turn right on 3rd street to Market Street. Turn left on Market Street. Continue until Market Street becomes college drive. Continue to college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Rt. 15 South: Turn left at market street. Continue on until Market Street becomes college drive. Continue on college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

Please complete the following questionnaire. Leave blank any parts you are unsure of, or do not wish to answer. Your answers will help with providing your care. We will review this form with you during your examination. All information will be kept confidential.

Patient Name:

What Pharmacy do you use?

What is the reason for your visit today?

History of your current problem (when it started, your symptoms and treatment if any):

Caffeine Use: What Kind: How Much:

Tobacco Use: Yes / No Current Former

Type: Smoking: How Often: Packs per Day:

Snuff (between lower lip and gum): How Often: Cans per Day:

Chew (between cheek and gum): How Often: Cans per Day:

Quit Date:

Alcohol Use: Yes / No Current Former

How Often: How Much:

Illicit Drug Use: Yes / No Current Former

How Often: How Much:

Have you had any recent falls in the last 12 months: Yes / No

Dominant Hand: Left / Right

Your medical history: Please check all previous illness or conditions below.

__ Chronic Obstructive Pulmonary Disease __ Hypothyroidism (Underactive Thyroid)

__ Asthma __ Thyroid Nodule (Lump in Thyroid Gland)

__ Hypertension (High Blood Pressure) __ Hyperparathyroidism

__ Coronary Artery Disease __ Hashimoto’s Disease (thyroid gland inflammation)

__ Myocardial Infarction (Heart Attack) __ Hypocalcaemia (too much calcium in blood)

__ Congestive Heart Failure __ Osteopenia (Mild Bone loss)

__ Hyperlipidemia (High cholesterol) __ Osteoporosis (Severe Bone Loss)

__ Diabetes __ Vitamin D Deficiency

__ Chronic Renal Failure __ Kidney Stones

__ Obesity __ Hyperthyroidism (Overactive Thyroid)

Do you have a history of prior cancers?

Any other problems not listed?

Blood Transfusion: Yes / No If Yes: When

Surgical History:

Type: Approximate Date:

Have you ever been hospitalized? Yes / No Hospital:

Please tell us the reason why and when?

Family Medical History:

Age Diseases If Deceased, Cause of Death

Father

Mother

Sisters

Brothers

Others

Check if your blood relatives had any of the following:

Relationship to you: Paternal/Maternal/Alive/Deceased

Arthritis

Asthma

Cancer Type:

Chemical Dependency

Colon Polyps

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Stroke

Tuberculosis

Other (specify)

Current Medications (include hormones, over the counter drugs, vitamins, and herbs):

Name of Medicine: Dosage: How often: Tablet/Capsule: Reason for taking:

Are you allergic to anything? __ Yes __ No

List all ALLERGIES to anything and describe your reaction.

Allergies: Reaction:

Food:

Drug:

Latex:

Review of Systems: Please check all of the following problems you are having now.



Wabash General Hospital

General Surgery

1430 College Drive, Suite B

Mt. Carmel, IL 62863

General Musculoskeletal Gastrointestinal

__ Chills __ Back Pain __ Abdominal Pain

__ Fever __ Bone Pain __ Black Stools

__ Decreased Appetite __ Joint Pain __ Blood in stools

__ General Discomfort/Fatigue __ Joint Stiffness __ Constipation

__ Night Sweats __ Muscle Pain __ Diarrhea

__ Pain (Location: ______) __ Muscle Weakness __ Difficulty Swallowing

__ Weakness __ Neck Pain __ Heartburn

__ Weight Gain __ Trauma/Injury (______) __ Nausea

__ Weight Loss __ Painful Swallowing

__ Falls Hem/Lymph __ Vomiting

__ Anemia

Endocrine __ Easy Bruise/Bleed Neurological

__ Cold Intolerance __ Lymphedema (Swelling) __ Confusion

__ Heat Intolerance __ Swollen Glands __ Dizziness

__ Diabetes __ Fainting

__ Polydipsia (Excessive thirst) Head/Ears/Nose/Throat __ Headache

__ Hot Flashes __ Hearing Changes __ Lightheadedness

__ Hearing Loss __ Memory Changes

Eyes __ Hoarseness __ Numbness: (______)

__ Blurred Vision __ Mouth Ulcers __ Parenthesis feeling

__ Double Vision __ Nose Bleeds __ Seizure

__ Eye Pain __ Otalgia (Ear Pain) __ Speech Changes

__ Tearing __ Ringing in Ears __ Unbalanced Walking

__ Vision Changes __ Runny Nose __ Focal Weakness

__ Yellow Eyes __ Sore Mouth

__ Throat Pain Psychiatric

Genitourinary __ Depression

__ Blood in Urine Respiratory __ Hallucinations

__ Burning Urination __ Cough __ Insomnia

__ Difficulty Controlling Urine __ Coughing Blood __ Anxiety

__ Excessive Urination __ Shortness of Breath __ Substance Abuse

__ Frequency __ Sputum Production __ Suicidal Thoughts

__ Sexual Dysfunction __ Wheezing

__ Urgency __ Pleuritic (Chest) Pain Skin

__ Vaginal Bleeding __ Bruises

__ Vaginal Problems Cardiovascular __ Bumps

__ Mass __ Chest Pain __ Changes in Moles



Wabash General Hospital

General Surgery

1430 College Drive, Suite B

Mt. Carmel, IL 62863

__ Incontinence __ Palpitations __ Itching

__ Leg Swelling __ Nail Changes

Breast __ Leg Pain __ Rash

__ Breast Pain __ Paroxysmal Nocturnal __ Skin Changes

__ Breast Mass Dyspnea (Shortness of Breath __ Sores

__ Nipple Discharge & coughing at night)

__ Breast Self-Exam __ Orthopnea

__ Skin Changes