New Patient Intake Form

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Bertha Benson
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1 Matthew R. Stanfield M.D. Neurosurgeon New Patient Intake Form I. Identifying Demographic and Social Information Name: (First) (Middle) (Last) Birth/Maiden Name: Date of Birth / / Gender: q Male or q Female Marital Status: q Single q Married q Widowed q Separated q Divorced Social Security Number: Occupation: q Employed q Retired q Student Driver License Number: License Expires: State: Street Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Address: Patient Employer: Employer Address: Street City State Zip Emergency Contact Name: Relationship to Patient: Phone: Language: q English or q Other: Race: Religion: II. If Patient is a Minor, Responsible Party (If applicable) Name: Occupation: Social Security Number: Phone: _ Street Address: Street City State Zip Employer: Employer phone: Employer Address: Street City State Zip Is this visit related to worker s compensation? q Yes q No Is this visit related to any legal actions? q Yes q No If this problem is the result of an accident, when did the accident occur?

2 III. Primary Health Insurance Policy Information Health Insurance Company: Insured Policy Identification Number: Group Number: Policy Holder Name/Subscriber Name: Relationship to Insured: q Yourself q Spouse q Parent q Other: _ (If you checked that the policy holder/subscriber relationship to Insured is someone other than yourself please provide the following) Policy Holder/Subscriber Social Security Number: Policy Holder/Subscriber Employer: Policy Holder/Subscriber Date of Birth / / IV. Secondary Health Insurance Policy Information (If applicable) Health Insurance Company (Secondary): Insured Policy Identification Number: Group Number: Policy Holder/Subscriber: Social Security Number: Relationship to Insured: q Yourself q Spouse q Parent q Other: _ (If you checked that the policy holder/subscriber relationship to Insured is someone other than yourself please provide the following) [Type Policy a Holder/Subscriber quote from the document Employer: or the summary of an interesting Policy Holder/Subscriber point. You can position Date of the Birth text / / box anywhere in the document. Use the Drawing Tools tab to change the formatting of the pull quote text box.] HIPPA) I authorize practice/billing company to contact me about my bill reaching me via: (If all boxes are checked no we will require prepayment on all services) Phone: q Yes q No Cell phone: q Yes q No Work phone: q Yes q No Mail: q Yes q No Benefits to Physician: I hereby authorize payments directly to Matthew Stanfield, M.D. of the surgical and/or medical benefits. I understand that I am responsible for any portion of my bill not covered by my insurance company within the terms of its contract. Signed (Patient or Parent of Minor): Release of Information: I hereby authorize release of information necessary for filing my insurance claim or filing a payment review. Signed (Patient or Parent of Minor): I have received a Notice of Privacy Practices from the office of Matthew Stanfield, M.D. Signed: Date: _ I have signed the patient consent for use and disclosure of protected health information from the office of Matthew Stanfield, M.D. Signed: Date: _ You may speak with the following person(s) about my bill regarding medical services provided: Name: Relationship: Phone: You may not speak with the following person(s) about my bill regarding medical services provided: Name: Relationship:

3 V. Physician Care Information (Please provide First and Last names) Primary Care Physician: Referring Physician (if different from PCP): Specialty*: Other Physician: Specialty*: Other Physician: Specialty*: *Specialty examples: Lung= Pulmonologist, Heart=Cardiologist, Nerves=Neurologist, Endocrinologist=Hormones/Glands, Urologist=Urinary, Orthopedic=Muscle/Skeletal, etc. Pharmacy: Pharmacy Location: VI. Reason for Visit Chief Complaint (History of Present Illness) Please describe the major problem that brings you in today to see a Neurosurgeon: VII. Family History Do you have a family member affected with : Condition Yes No type /affected relative Condition Yes No type /affected relative Cancer (Non Brain) q q Bleeding/Clotting q q Glioma q q Heart Disease q q Meningioma q q High Cholesterol q q Brain Aneurysm q q Hypertension q q Other Aneurysms q q Diabetes q q Other Conditions q q Write other conditions: VIII. Pain Assessment Do you experience pain as a part of your daily life? q Yes q No If yes, please describe the location(s), onset, duration, and characteristics of your pain: If yes, on a scale of 1 to 10 (0=no pain, 10=the worst pain), how would you rate your pain? _

4 IX. Surgical History Please list all operations you have had: Date: X. Medical History Please list all medical conditions: Duration: Please list all MEDICATIONS you take routinely, prescribed or over the counter, along with dosages: Medication: Dose: Frequency: _ Are you ALLERGIC to any medicines, latex, X-ray dye, or iodine? q Yes q No If yes, please explain: Are you taking any blood thinning medications? q Yes indicate below q No Aspirin or aspirin-containing medication q Anti-inflammatory medicine q Plavix q Coumadin q Fish Oil q Other:

5 XI. Social Information and History (Continued) Education Completed: Number of Children: Do you Smoke cigarettes? q Yes q No If yes, how many packs a day? If yes, at what age did you start smoking? If applicable, at what age did you stop? Do you drink alcohol? q Yes q No If yes, how much daily? If yes, at what age did you start drinking? If applicable, at what age did you stop? Do you use recreational drugs? q Yes q No Do you exercise regularly? q Yes q No If so, what type of drug(s)? How frequently? Females: Are you, or could you be pregnant? q Yes q No Age at last menstrual period? Have you ever used Oral Contraceptives? q Yes q No Have you ever used Hormone Replacement Therapy? q Yes q No XII. Health Care Proxy? Do you have a Health Care Proxy? (check one) q Yes q No If yes, please list: The information on this form is accurate to the best of my knowledge: Patient Signature Date completed Revised April 18, 2013

6 XIII. Review of Symptoms In the past 6 months have you had a problem with: Constitutional: Yes No Endocrine: Yes No Fever q q Diabetes q q Weight loss q q Thyroid disease q q Excessive fatigue q q Excessive thirst/urination q q History of Falls q q Genitourinary: Eyes: Urinary tract infections q q Wear glasses q q Painful urination q q Infections q q Blood in your urine q q Injuries q q Difficult start/stop stream q q Glaucoma q q Incontinence q q Cataracts q q Kidney stones q q Ear, Nose, Throat & Mouth: Musculoskeletal: Wear hearing aids(s) q q Broken bones q q Hearing loss q q Arm or leg weakness q q Ear pain/infections q q Arm or leg pain q q Ringing in ears q q Joint pain or swelling q q Nose bleeds q q Arthritis q q Nasal congestion/drainage q q Integumentary: Inability to smell q q Skin disease q q Sinus problems q q Breast pain or tenderness q q Balance (vertigo,spinning,etc.) q q Neurological: Cardiovascular: Fainting Spells or black outs q q Chest pain or angina q q Seizures q q High blood pressure q q Problems with memory q q Irregular pulse q q Disorientation q q Heart murmur q q Difficulty with speech q q High cholesterol q q Inability to concentrate q q Swelling in hands or feet q q Double or blurred vision q q Leg pain while walking q q Weakness in arms and/or legs q q Respiratory: Loss of sensation q q Asthma q q Difficulty with balance q q Emphysema q q Psychiatric: Shortness of breath q q Anxiety q q Pneumonia q q Depression q q Bloody sputum q q Hematologic/Lymphatic: Gastrointestinal: Anemia q q Nausea q q Hemophilia q q Vomiting q q Bleeding tendencies q q Blood in your vomit q q Blood transfusion q q Liver disease q q Swollen glands/lymph nodes q q Jaundice q q HIV q q Abdominal pain q q Allergic/Immunologic: Change in bowel habits q q Food, Inhalant, nasal allergies q q Ulcers or gastritis q q Autoimmune disease q q

7 Matthew R. Stanfield, M.D. Neurological Surgery 5500 North Portland Avenue Oklahoma City, OK Office: Fax: Patient Name: Appointment Date: Appointment Time: Please call 24 hours before your appointment if you need to reschedule. Thank you!

8 Matthew R. Stanfield, M.D. Neurological Surgery Please fill out the enclosed paper work and bring it with you to your appointment. Please bring a COPY (disk or films) of all your X-Rays/MRIs/CTs with you on the day of your appointment. If you do not bring a COPY of all your imaging, we will have to reschedule your appointment. Due to the complexity of neurosurgery, our scheduled appointments may run over the allotted time depending on your individual diagnosis. Please understand if your appointment has been delayed that you will receive the same high standard of patient care as the person before you. Dr. Stanfield is a practicing physician at Deaconess Hospital and is always on call for emergencies. Therefore your appointment may be delayed or rescheduled. You are invited to bring a book, crossword, etc. Our Office has handicap parking spaces available for our patients regardless of disability. If you are unable to make your scheduled appointment please call to cancel or reschedule as soon as possible. This will allow us to schedule another patient who is in pain and needing to see Dr. Stanfield. We thank you in advance for your patience. Thank you, Dr. Matthew Stanfield s Office 5500 North Portland Avenue, Oklahoma City, Oklahoma Office: (405) Fax: (405)

Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:

Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?