Adena Family Medicine- Washington Court House 308 …

[Pages:4]Adena Family Medicine- Washington Court House 308 Highland Avenue Suite C

Washington Court House, Ohio 43160 Toll free (855) 232-9274

WELCOME TO OUR PRACTICE!

We are pleased that you have chosen Adena Family Medicine Washington Court House as your medical home. Your health is our priority. We will make every effort to meet your expectations based on your individual healthcare needs. We are looking forward to establishing long-term relationships with our patients.

Enclosed you will find a health history form that needs completed and brought to your first visit. This information will be placed into electronic medical records to ensure accuracy for this visit and future visits. If you have any questions regarding this information, please speak to the receptionist. We must also have a copy of your most recent insurance card, a photo ID, and a list of your current medications. If the patient is a child please provide us with a current shot record.

If you no show for your new patient appointment, we will not be able to reschedule you at this office. Any patient that fails to arrive for a scheduled appointment without cancelling the appointment prior to the scheduled time will be considered a "no show".

Chronic cancellations and/or no shows for scheduled appointments could result in a discharge from this practice. Any patient that "no shows" 3 times from this practice will be sent through the discharge process.

Payments are required at the time of service. This includes self pay, co-payment and deductibles. If you are unable to pay at the time of service, please ask the receptionist for financial aid information prior to your visit. Uninsured patients will be expected to pay $125.00 at the time of service for their first appointment.

If you receive a patient satisfaction survey in the mail, we would appreciate your response to the care you received. Your opinion matters to us. If you do not feel you receive very good care, please ask to speak to the Office Manager.

Thank you for choosing us as your healthcare provider.

Wishing you the best of health,

Adena Family Medicine Washington Court House Providers & Staff

Adena Family Medicine- Washington Court House

Name:_____________________ ____ Date of Birth: ______________ Home Address: ______________________________________________ Social Security Number: _______________ Patient Sex: ______________ Patient Phone Number: ______________Work: ______________________ Cell: ___________________

E-mail:_____________________________________________________________________________

Who referred you to this office?: _______________________________________________________

Occupation: __________________________ Employer: _____________________________________

Emergency Contact Name: _____________________________________________________________

Relationship: _________________________ Phone Number: __________________________________

Work Number: ________________________ Cell Number: _________________________________

Insurance Name: MEDICARE

Insurance Address: ____________________________________________________________________

Subscriber Name: _______________________________ Subscriber Date of Birth: __________________

Secondary Coverage: ___________________________________________________________________

Was injury work related? Y N Date of Injury: ____________________ Claim # ___________________

Social History

Tobacco (current or former) Y N Packs Per Day _____ How Long? _____ Age Quit _____

Alcohol

Y N Drinks/Week _____ Any past problems? ________________

Caffiene

Y N Cups/Day _____

Substance Abuse

Y N Describe: __________________________________________

Special Diet

Y N Describe: __________________________________________

Exercise

Y N Describe: __________________________________________

Pharmacy Name: ______________________________________________________________________

Drug Allergies: ________________________________________________________________________

Surgeries/Hospital Admissions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Medical Conditions

Self

List Relatives (Mother, Father, Grandparent,Brother,Sister)

Heart Attack/Heart Disease

High Blood Pressure

Stroke

Sugar/Diabetes

Cancer/Leukemia

Seizures/Epilepsy

Arthritis/Gout

Breathing/Lungs/TB

Stomach/Ulcer/Reflux

Bowel Problems

Anemia/Phlebitis/Bleeding

Kidney/Bladder Problems

Hepatitis/Liver Disease

Thyroid (Hyper/Hypo)

Glaucoma/ Eye Problems

Mental Illness/Depression

Anxiety

STDs

Alcoholism/Drug Use

Other:

Current Medications and dosages:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Year of last: Colonoscopy: _______ Tetnus Shot: _______ Flu Shot: _______ MMR: _______

Review Of Systems ? Please circle

Constitutional Eyes Ears, Nose, Throat Cardiovascular Respiratory Gastrointestional

Musculoskeletal Urinary Genital Neurologic Skin Endocrine Hemotologic Psychiatric

Fever Night Sweats Fatigue Unexplained weight loss Eye Pain Double Vision Visual Changes Ear Pain Sore Throat Nasal Congestion Difficulty Swallowing Chest pain Palpitations Irregular heart beat Shortness of breath Cough Wheezing Bloody Sputum Abdominal Pain Nausea/Vomiting Diarrhea Constipation Heartburn Blood in stool Joint Swelling Joint Pain Difficulty Walking Incontinence Painful urination Slow Urinary Stream Vaginal/Penile Discharge Sexual Dysfunction Headaches Muscle Weakness Fainting Numbness/Tingling Rashes Wounds that don't heal Changing Moles Excessive thirst Cold Intolerance Anemia Prolonged Bleeding Easy Brusing Depression Anxiety Panic Attacks Insomnia

Females Only Age at onset of menstrual period: _____ Number of pregnancies: _____ Abortions: _____ Number of Living Children: _____ Birth Control: ______________ Gardisil Injection: _________ Year of Last Breast Exam: ________ Mammogram: ________ Pap: ________ Any abnormal results? ________________________________ Self breast exam? Y N

Males Only Year of Last: Prostate Exam: ________ PSA: ________

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