Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age:

Transcription

1 Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age: Reason for today s visit: Medications (include Aspirin, vitamins and herbal remedies, birth control and over-the-counter allergy and cold meds): Allergies to Medications: None known Your Past Medical History: Yes No (please explain if yes) Diabetes O O High Blood Pressure O O Thyroid disease O O Heart Disease O O Heart Murmur O O Elevated Cholesterol O O Respiratory/lung disease O O Digestive/stomach/intestinal disease O O Urologic/kidney disease O O Neurologic/seizure/depression O O Glaucoma/eye disorder O O Environmental Allergy O O Cancer O O Other Medical Disease O O Autoimmune Disease O O No prior surgery Previous Surgery (include operations and dates): Social Hx What is your occupation? Former occupation if retired How much do you smoke? packs/day (Check if none O) If none, did you ever smoke? If yes, when did you quit? How often do you drink alcohol? Caffeine Use If Yes, please list source and frequency Exposed to high level of Environmental noise Family Hx Please note which relatives have had the following: Yes No (please explain if yes) Cancer O O Hearing Loss O O Allergy O O Bleeding disorders O O Diabetes O O Headaches O O Heart Disease O O Adverse reaction to anesthesia O O (Malignant Hyperthermia?) Reviewed by: M.D. Date

2 Ear, Nose & Throat Consultants Patient Medical Hx Form, page 2 Patient name Perinatal/Birth Hx Premature/Infection/Jaundice/Intubation/Oxygen/Breathing difficulties? Newborn hearing test: Normal/Abnormal/ Not known / Not done Review of Systems Please indicate whether you presently have any of the following symptoms: Constitutional Chills O O Fatigue O O Weight loss/gain O O Daytime fatigue O O Eyes Eye pain O O Watery O O Itchy eyes O O Blurred vision O O Ears, Nose, Mouth, Throat Ear pain O O Ear itch O O Ear drainage O O Dizziness / Loss Of balance O O Loss of Hearing O O Popping Noise O O Tinnitus O O Nosebleeds O O Post-nasal Drip O O Sinus pain O O Sinus pressure O O Nasal congestion O O Loss of smell/taste O O Hoarseness O O Sore throat O O Throat tickle O O Dry Mouth/Throat O O Throat clearing O O Snoring O O Cardiovascular Irregular heart beats O O Chest pain O O High Blood Pressure O O Heart failure O O Heart Murmur O O Respiratory Cough O O Short of Breath O O Wheeze O O Asthma O O Coughing up blood O O Yes No Yes No Gastrointestinal Heartburn O O Burping O O Trouble swallowing O O Genitourinary Troubles with urination O O (Females) Are you pregnant or trying? O O Post-menopausal O O Musculoskeletal Joint pain O O Muscle aches O O Skin Rash O O Itching O O Hives O O Change in skin O O Change in hair O O Neurological Headaches O O Fainting O O Slurred speech O O Psychiatric Depression O O Anxiety O O Panic Disorder O O Endocrine Thyroid Overactive O O Thyroid Underactive O O Thyroid nodules/lumps O O Hematologic/Lymphatic Swollen glands O O Night sweats O O Bleeding disorder O O Clotting disorder O O Easy bruising O O Allergic/Immunologic Sneezing O O Itchy nose O O Itchy eyes O O Previous allergy tests O O Height: Weight: Reviewed by: M.D. Date

3 Date: Ear, Nose and Throat Consultants Patient Registration Form Name / Address Last Name: First Name: MI: If minor: Parent s name: Street Address: City: State: Zip: - Home Phone: ( ) - Cell phone: ( ) - Work Phone: ( ) - Employer: Statistics Soc. Sec: #: - - Date of Birth: / / Sex: Male/Female Marital Status (Circle one) Married, Single, Divorced, Widow, Other Emergency Contact : Contact Tel #: ( ) - **Optional: Please write N/A if you decline to answer the following information** Primary Language : Ethnicity Race Referring Physician Primary Care Doctor: Referring MD if not PCP: Address: Tel: ( ) - Insurance Information Primary Insurance Company Identification or Certificate # Group # Name of insured if not self: Relation to Insured (circle one) Self, Spouse, Child Insured Date of Birth: / / Insured Soc. Sec : #: - - Insured Employer: Secondary Insurance Company Identification or Certificate # Group # Name of insured, if not self: Relation to Insured (circle one) Self, Spouse, Child Insured Date of Birth: / / Insured Soc. Sec : #: - - Other Insurance Is this Workers Comp.? Y/N Is this Motor Vehicle? Y/N Is this Personal Injury? Y/N Authorization and financial Policy I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS FOR MEDICAL BENEFITS. I AUTHORIZE PAYMENT OF ALL MEDICAL BENEFITS TO ENT CONSULTANTS FOR SERVICES PROVIDED. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AND ALL BALANCES NOT PAID BY MY INSURANCE COMPANY. Your Signature:

4 Ear, Nose, & Throat Consultants, Inc. Jeffrey S. Brown, M.D., F.A.C.S. Annemarie Czarnota, M.S.,CCC-A Thomas H. Costello, M.D. F.A.C.S Alysia S. Moon, Au.D., CCC-A Andrew M. Doolittle, M.D. Rachael E. Zugel, M.S., CCC-A K. Holly Gallivan, M.D., M.P.H.,F.A.C.S. Hearing and Balance Center Dukhee Rhee, M.D. Elizabeth A. Ketter, PA-C Karen Iliades, R.N. (Allergy/ ENT) Billing Policy Patient Name: Chart # (staff to complete) Referrals, co-payments and deductibles for services rendered are your responsibility. Office procedures may be required to provide you appropriate care. Procedures might include nasal endoscopy, excision of lesions, biopsies, removal of impacted ear wax, and flexible fiberoptic laryngoscopy, or other office procedures deemed necessary by the provider. Some insurance companies bill these procedures under their surgery guidelines. You may be responsible for a separate co-pay or deductible for surgical procedures after insurance payments and adjustments. By signing this form I acknowledge that I am requesting evaluation and treatment from ENT Consultants. I understand that I am financially responsible for payment and any residual balance after insurance payments, if applicable. I will also be held responsible for obtaining a referral from my primary care doctor. I understand that during evaluation of my problem, certain common procedures may be required. Different insurance policies may handle the payment of these procedures differently. I have the right to notify the provider prior to a procedure if I choose not to have the procedure: otherwise, my signature on this form represents consent for these commonly done procedures. I will assume liability if a diagnosis is delayed or missed due to my refusal. This agreement is valid for the duration of your care for any of the providers at Ear Nose & Throat Consultants, Inc. Please feel free to ask questions if you have any concerns regarding this agreement. You are responsible for the timely payment of your account. Patient / Guardian Signature X Relationship: Self / Guardian / Other Date: A complete description of our financial policies is posted at the check-in desk and is available upon request.

5 Patient Name : DOB: EAR, NOSE AND THROAT CONSULTANTS, INC. ACKNOWLEDGMENT AND CONSENT By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the medical group listed at the beginning of this notice, and how I may obtain access to and control of this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information from my Health Care Provider. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the medical group, its staff, and its business associates. Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative s Authority