PATIENT DATA - cthandspecialists.com · HEALTH HISTORY Welcome to our practice. As a new patient,...
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Patient Name PATIENT DATA (PLEASE PRINT) D.OE. Address~~~~~~~~~~~~~~_City~~~~~~~~~~~_ Zip Code~~~~~~_Home#~~~~~~~~~_Cell# _ Soc. Sec. # Sex: Male Female Marital Status: Single Married Widowed Separated Divorced Occupation work # _ Employed by _ Employer's Address _ Name ofSpouse _ Or Parent (if child) Occupation ~-----Work #_~~~~~~~~~~~~ Employed by _ Employer 's Address~~~~~~~~~~~~~~~~~~~~~~~~_ Primary Care Physician _ Name and number of Pharmacy _ Referred by ~_ Whom may we contact in case of emergency? _~~~~~~~~~~~~~~~~~~~phone#~~~~~~~~~_ I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. Signature Date _ Parent (if minor) Date _
Transcript of PATIENT DATA - cthandspecialists.com · HEALTH HISTORY Welcome to our practice. As a new patient,...
Patient Name
PATIENT DATA(PLEASE PRINT)
D.OE.
Address~~~~~~~~~~~~~~_City~~~~~~~~~~~_
Zip Code~~~~~~_Home#~~~~~~~~~_Cell# _
Soc. Sec. # Sex: Male Female
Marital Status: Single Married Widowed Separated Divorced
Occupation work # _
Employed by _
Employer's Address _
Name ofSpouse _Or Parent (if child)
Occupation ~-----Work #_~~~~~~~~~~~~
Employed by _
Employer 's Address~~~~~~~~~~~~~~~~~~~~~~~~_
Primary Care Physician _
Name and number of Pharmacy _
Referred by ~_
Whom may we contact in case of emergency?_~~~~~~~~~~~~~~~~~~~phone#~~~~~~~~~_
I understand and agree that (regardless of my insurance status), I am ultimatelyresponsible for the balance of my account for any professional services rendered.
Signature Date _
Parent (if minor) Date _
Connecticut Hand SpecialistsMichael T. Legeyt, M.D.
Your privacy is important to us..
Please take afew minutes to fill out this form to ensure your confidentiality. Without yourwritten authorization, we cannot disclose ANY information to friends or relatives whowish to inquire about you or translate for you.
Patient name-------------------Guardian if child under 18 _
Please list any person in whom we may disclose information about your health and yourdiagnosis (including treatment, payment and health care options)
Can we leave messages on your answering machine? (Appointment reminders) yes no
Here at Dr. LeGeyt's office we comply with the HIP PA Privacy Act. This is in place toprotect your health information from being disclosed. If at anytime you would like to readthe HIPPA Privacy Act there is a copy available at the receptionist'sdeskfor yourviewing.
Signature ' Date _
Some services and/or items we offer here mayor may not be covered by your insurancecarrier. The fact that your insurance carrier may not pay for a particular item does notmean that you should not receive it. There may be a good reason why Dr. LeGeyt isrecommending it. Some items that may not be covered are:
~Fittings offorearm brace~Dressing changes~Ace Bandages~Premium casting (waterproof)
We are making you aware of this so you may make an informed choice about whether ornot you want to receive these items if needed, knowing that you may be responsible forthe payment of them .•
Please choose an option below then sign and date.Yes I want to receive these items if needed. The claim will be submitted to yourinsurance and if the deny payment you agree to pay the balance infull.
'....
No I have decided not to receive these items or services.j i
Signature Date _
HEALTH HISTORY
Welcome to our practice. As a new patient, please fill out the information found below to the best of your ability.
Patient Name _
ChiefComplaint: _
History of present illness: .•
(Does the pain/problem occur at a specific time?)
-location: _
(Where is the pain/problem?)
Severity _(How severe is the problem on a scale of 1-5 with 5 being most severe?)
Timing -----~~:w-:~~:;;~~~ifk7;;;~)------Associated signs/symptoms _
Quality _(Example: normal versus abnormal color, activity, etc.)
Duration _(How long have you had this pain/problem?, or When did it start?)
Context _(Where were you at the onset of this pain/problem?)
Modifying factors _
(What other associated problems have you been having?)
Past Medical HistoryHave you ever had the following: (Circle "no" or "yes", leave blank if uncertain)
(What makes the pain/problem worse or better?, or,Have you had previous episodes?)
Previous Hospitalizations/Surgeries/Serious Illnesses
Measles no yes
Mumps no yesChickenpox no yesWhooping Cough no yesScarl~t Fever _no yesDiphtheria no yesSmallpox no yesPneumonia no yesRheumatic Fever no yesHeart Disease no yesArthritis no yesVenereal Disease no yes
Anemia ............................ noyesBladder Infections ............
noyesEpilepsy ...........................
noyesMigraine Headaches ........
noyesTuberculosis ....................
noyesDiabetes ..........................
noyesCancer .............................
noyesPolio ................................
noyesGlaucoma ........................
noyesHernia ............. L ............
noyesBlood or Plasma Transfusions ..................
noyes Back Trouble .................... noyes Hepatitis ..........................noyesHigh Blood Pressure ........
noyes Ulcer ...............................noyesLow Blood Pressure .........
noyes Kidney Disease ................noyesHemorrhoids ....................
noyes Thyroid Disease ...............noyesDate of last chest x-ray
Bleeding Tendency ..........noyesAsthma ............................
noyes Any other disease .............noyesHives or Eczema ..............
noyes (please list):AIDS or HIV+ .................
noyesInfectious Mono ...............
noyesBronchitis ........................
noyesMitral Valve Prolapse .......
noyesStroke ..............................
noyes
When?Hospital, City, State
Medications: (Include nonprescription) _
Have you ever taken Fen-Phen/Redux? no yes
Patient Social History:• Marital Status: 0 Single 0 Married - 0 Separated 0 Divorced 0 Widowed• Use of Alcohol: 0 Never 0 Rarely 0 Moderate 0 Daily
• Use of Tobacco: 0 Never O. Previously, but quit Current packs/day: _• Use of Drugs 0 Never 0 Type/Frequency: _• Excessive Exposure
at home or work to: 0 Fumes 0 Dust 0 Solvents 0 Air-borne Particles 0 Noise
Patient Medical History:Age
Father
Mother
Siblings
Spouse
Children
Diseases If Deceased, Cause of Death
Review of Systems: Please indicate any personal history below:
o Constitutional Symptoms
o GenitourinaryGood general health lately ............
no yesFrequent urination ........................no yesRecent weight change ...................
no yesBurning or painful urination ..........no yesFever ............................................ no yesBlood in urine ..............................no yesFatigue ..........................................
no yesChange in force of strainHeadaches .................................... no yes
when urinating ............................. no yes
o Eyes
Incontinence or dribbling .............no yes
Kidney stones ...............................no yes
Eye disease or injury .....................no yesSexual difficulty ............................ no yes
Wear glasses/contact lenses ..........no yesMale - testicle paTn....................... no yes
Blurred or double vision ...............no yesFemale - pain with periods ............no yes
D.Ears/Nose/MouthlThroat
Female - irregular periods .............no yes
Female - vaginal discharge ............no ye?.,
Hearing loss or ringing ..................no yesFemale - # of pregnancies .............Earaches or drainage .....................
no yesFemale - # of miscarriages .............Chronic sinus problem or rhinitis ..
no yesFemale - date of last pap smear .....Nose bleeds ..................................
no yesMouth sores..................................
no yeso Musculoskeletal
Bleeding gums ..............................no yesJoint pain ......................................no yesBad breath or bad taste ................. no yesJoint stiffness or swelling ...............no yes
Sore throat or voice change ..........no yesWeakness of muscles or joints ......no yes
Swollen glands in neck .................no yesMuscle pain or cramps ..................no yes
o Cardiovascular
Back pain .....................................no yes
Cold extremities ...........................no yesHeart trouble ................................ no yesDifficulty in walking .....................no yes
Chest pain or angina pectoris ........no yeso Integumentary (skin, breast)
Palpitation .................................... no yesShortness of breath w/walking
Rash or itching ..............................no yesor lying flat ...................................
no yesChange in skin color .....................no yesSwelling of feet, ankles or hands ...
no yesChange in hair or nails ..................no yesVaricose veins ..............................
no yeso Re'spiratory Breast pai n....................................no yesChronic or frequent coughs ..........
no yesBreast lump ..................................no yesSpitting up blood ..........................
no yesBreast discharge ............................no yesShortness of breath ....................... no yesWheezi ng .....................................
no yeso Neurological
o Gastrointestinal
Frequent or recurring headaches ...no yes
Light headed or dizzy ...................no yes
Loss of appetite ............................. no yesConvulsions or seizures ................no yes
Change in bowel movements .......no yesNumbness or tingling sensations ... no yes
Nausea or vomiting ......................no yesTremors ........................................no yes
Frequent diarrhea .........................no yesParalysis .......................................no yesPainful bowel movements Head injury .................................. no yes
or constipation ..............................no yes
Rectal bleeding or blood in stool ..no yes
Abdominal pain ............................no yes
o PsychiatricMemory loss or confusion .............
no yesNervousness .................................
no yesDepression ...................................
no yesInsomnia .... '" ................................
no yes
o Endocrine Glandular or hormone problem ....
no yesExcessive thirst or urination ..........
no yesHeat or cold intolerance ............... no yesSkin becoming dryer .....................
no yesChange in hat or glove size ...........
no yes
o Hematologic/lymphaticSlow to heal after cuts ...................
no yesBleeding or bruising tendency ......
no yesAnem ia .........................................
no yesPhlebitis .......................................
no yesPast transfusion .............................
no yesEnlarged glands ............................
no yes
o Allergic/ImmunologicHistory of skin reaction or other adversereaction to:
Penicillin or other antibiotics no yesMorphine, Demerol,or other narcotics no yesNovocain or other anesthetics no yesAspirin or other pain remedies no yesTetanus antitoxin
or other serums no yesIodine, Merthiolate orother antiseptic. no yes
Other drugs/medications: _
Known food allergies:_
Environmental allergies: _
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrectinformation can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medicalstatus. I also authorize the healthcare staff to perform the necessary services I may need.
Signature of Patient, Parent or Guardian
Doctor's Review
Signature of Doctor
Date
Date
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