ࡱ> MOJKLa Cbjbjڤڤ hjCbCb, $222P\\2(cz:(bbbb#b%b%b%b%b%b%b$eXhpIbIbbbHbJ"J"J"Rbb#bJ"#bJ"J"kZW`b@W<c\8bb0(c\h hpW`hW`J"IbIbJ"(ch B :  PATIENT DEMOGRAPHIC INFORMATION PATIENT INFORMATIONTodays Date: MRN: Account Number: Patient Name: Nickname:Mailing Address: Email Address: Home Phone: Cell Phone: Work Phone: Can we leave a message? % Y % N % Y % N % Y % NDOB: Sex: Marital Status:  EMERGENCY CONTACT INFORMATIONEmergency Contact Name: Phone Number:  RESPONSIBLE PARTYGuarantor Name: DOB: Address:  INSURANCE INFORMATIONPrimary Insurance:  MERGEFIELD InsuranceName \* MERGEFORMAT Secondary Insurance:  MERGEFIELD InsuranceName \* MERGEFORMAT Address: Address: Phone Number: Phone Number: Subscriber Name: Subscriber Name: DOB: DOB: Subscriber ID: Subscriber ID: Group Number: Group Number:  EMPLOYER INFORMATIONPatient Employer: Patient Occupation: ADVANCED DIRECTIVEPlease provide our office with a copy and check the box if you have any of the following in place: % POA % Living Will %DNR %None ETHNICITY/RACE/LANGUAGEWhich category best describes your race? Please select all that apply % African American % Asian % Caucasian % Other__________ % Decline to answerAre you of Hispanic or Latino descent? % No % Yes % Decline to answerWhat is your preferred language? % English % Spanish % French % Other______________  Medical Hills New Patient Information Name: DOB: Current MedicationsPrescribed MedicationsSizeDoseFrequencyPrescriberLipitor(example)40mg tablet1 tabletOnce a dayDr. Med HillsMedication Allergies / IntolerancesPlease list medications you are allergic to (or cannot tolerate).Reaction:Example: Penicillin Example: rash, difficulty breathing Past Medical HistoryHave you been treated for any of the following conditions? Please circle all that apply.CardiovascularLung / ENTBowel/ UrologyBrain/ Nerve/ EyeMusculoskeletalEndocrine/ SkinCancer/ BloodHeart attack Heart failure Atrial fibrillation Palpitations Valve disease Heart murmur Hypertension Carotid disease PVD Passing outCOPD Emphysema Asthma Sleep apnea Pneumonia Lung clot (PE) Positive PPD TMD/ TMJ Ringing ears AllergiesPancreatitis Liver disease Reflux/ GERD Ulcers Colon disease Colon polyps Hemorrhoids Kidney disease Bladder disease Large prostateChronic headache Stroke/ TIA Seizures Memory loss Neuropathy Herniated disc Macular disease Retinopathy Cataracts Glaucoma Migrains19Arthritis Fibromyalgia Gout Osteoporosis Bursitis Back pain Knee pain Shoulder pain Hip pain Foot problemsHigh cholesterol Diabetes Thyroid disease Low testosterone Menopause Acne Psoriasis Eczema Skin cancer Hair/ nail diseaseProstate CA Breast CA Cervical CA Colon CA Anemia Bleeding disorder DVT/ blood clot Transfusion Hepatitis B or C HIVList any other conditions not included above or important facts related to any of the above: Mental Health HistoryCircle any of the following conditions that you have been treated for in the past:Depression Suicide attempt Anxiety Panic attacksDrug abuse Alcoholism Eating disorder Posttraumatic stress disorderADHD Bipolar disease Obsessive-compulsive disorder (OCD) PsychosisOther: Specialists/Other Medical CareAre You Currently Under The Care/Supervision Of Any Other Physician For Any Aspect Of Your Medical Care? & Yes & NoIf yes, please list the physician and condition they are treating you for:PhysicianCondition being treatedSexual HistoryAre you currently sexually active? NO YES Type of contraception: Have you been sexually active in the past? NO YES How many total sexual partners have you had in your lifetime? Have you ever been treated for a sexually transmitted disease? NO YES Type: Examples of STDs: gonorrhea, chlamydia, genital warts, herpes.Are you satisfied with your sex life? YES NO Concerns: Womens HealthBone HealthHave you ever had a spine or hip fracture? NO YES Date of last DEXA Scan: Date of last Vitamin D level:Has your mom or a sister been NO YES treated for osteoporosis?Do you take supplemental YES NO Calcium and Vitamin D? Age of first period: Are your periods regular?If no longer having periods, how old were you when they stopped?How often do you have a period?Total number of pregnancies: Number of stillbirths:Number of live deliveries: Number of miscarriages:Gestation diabetes? NO YES Pregnancy induced hypertension? NO YESNumber of abortions:Surgery/Procedure HistoryHave you had any of the following procedures (please circle)? If you can recall, add date.Tonsillectomy Adenoidectomy Cholecystectomy Appendectomy Bowel surgery Weight loss surgeryCarpal tunnel surgery Hip surgery Knee surgery Shoulder surgery Foot surgery Plastic surgery Breast BiopsyVasectomy Prostate surgery C Section Hysterectomy Tubal ligation Cystoscopy Cardiac catheterizationStress test Bypass surgery Stent placement Pacemaker Neurosurgery Back surgery Cataract surgeryHospitalizationsPlease list recent hospitalizations:DateReasonHospitalFamily HistoryPlease indicate any blood relative who has/had the following conditions with an X:Health Problem Circle Y or N for if family is livingMother Living Y/NFather Living Y/NSibling Living Y/NMaternal Grandma Living Y/NMaternal Grandpa Living Y/NPaternal Grandma Living Y/NPaternal Grandpa Living Y/N ChildHeart AttackStrokeHigh Blood PressureHigh CholesterolThyroid ProblemDiabetesBleeds easilyBlood ClotsDepressionSuicideSubstance AbuseSeizure DisorderCancer (Type)Social HistoryOccupationJob description: Company or place of work:Marital StatusSingle Divorced Widowed Married Separated RemarriedWhat is your spouses name? (if applicable)Childrens Names EducationWhat is your highest level of education?Where and when did you complete your education? Religion Local church or place of worship:CaffeineCups of coffee per day: What do you do for enjoyment?Alcohol1 drink=12-ounce beer/5 oz wine/1 shot liquor How many drinks do you have per day? 0 1-2 3-5 6-9 10 or more Have you ever sought treatment for drug or alcohol use? Yes NoHow many drinks do you have per week? 0 1-2 3-5 6-9 10 or more No Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? Yes No DrugsWhich drugs have you taken before (check all that apply)? ___ Methamphetamines (Speed, Crystal) ___ Cocaine ___ Cannabis (Marijuana, Pot) ___ Ecstasy ___ Tranquilizers (Valium) ___ Hallucinogens (LCD, Mushrooms) ___ Inhalants (Paint Thinner, Aerosol, Glue) ___ Narcotics (Heroin) ___ Barbiturates ___ SyntheticsHow many times in the last year have you used a street drug? None A few times Several times Most daysHow often do you use prescription drugs for non-medical reasons Not at all Some days Several times Most daysTobaccoWhich of the following tobacco products have you used in the last year? Smoke cigarettes or cigars Smoke e-cigarettes Dip Chewing tobacco Water pipes Hookahs Have often do you smoke/use tobacco? Not at all Some days Most days Every dayDo you need support to quit? Yes No Have you tried to quit tobacco within the last year? Yes No If yes, how did it go? Preventative Care HistoryColonoscopy Date of Last: & NeverResults: &Abnormal &Normal &UnknownMammogram Date of Last: & NeverResults: &Abnormal &Normal &UnknownPap Smear Date of Last: & NeverResults: &Abnormal &Normal &UnknownPSA (Screening for Prostate Cancer)Date of Last: & NeverResults: &Abnormal &Normal &UnknownSkin Exam by dermatologistDate of Last: & NeverResults: &Abnormal &Normal &UnknownFlu Shot/Influenza VaccineDate of Last: & NeverGardasil (HPV) VaccineDate of Last: & NeverPneumonia VaccineDate of Last: & NeverTetanus VaccineDate of Last: & NeverShingles VaccineDate of Last: & NeverHepatitis A Vaccine (2 shot series)Date of Last: & Never Hepatitis B Vaccine (3 shot series)Date of Last: & Neve!"67]^wx    R T   ! 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