Newborn hearing test: Normal/Abnormal/Not known/not done. Previous Surgery (include operations and dates):
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- Dominick Jones
- 5 years ago
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1 Ear, Nose & Throat Consultants - Pediatric Medical History Form Name: Date: / / Name of parents/ guardian(s): DOB: / / Age: Reason for today s visit: Medications (include vitamins and herbal remedies, birth control and over-the-counter allergy and cold meds): Allergies to Medications: None known Med rash/hives/swelling/anaphylaxis/breathing problem Med rash/hives/swelling/anaphylaxis/breathing problem Med rash/hives/swelling/anaphylaxis/breathing problem Perinatal / Birth History Premature/Infection/Jaundice/Intubation/Oxygen/Breathing difficulties? Newborn hearing test: Normal/Abnormal/Not known/not done Previous Surgery (include operations and dates): Social History In School (Yes/No) Grade Any special concerns? Important home info Exposure to cigarette smoke? Any pets at home? Behavioral problems at home or school? Family History 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 and Throat Consultants-Pediatric Medical History Form, page 2 Patient Name Patient s Past Medical History: Yes No (please explain if yes) Recurrent Ear Infections O O Number in prior 12 months Episodes requiring multiple antibiotics Drainage from the ear O O Concerns about hearing O O Concerns about speech delay O O Throat problems Tonsillitis O O Number in prior 12 months Excessive mouth breathing, heavy breathing O O Snoring (loud/ persistent) O O Witnessed apnea, pauses in breathing O O Nose problems Persistent stuffy nose O O Prior nasal injury O O Nosebleeds O O 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 / Autism / ADD / PDD O O Psychiatric / Depression / Anxiety O O Eye disorder / Glaucoma O O Environmental Allergy O O Cancer O O Autoimmune / Arthritis O O Other Medical Disease O O Reviewed by: M.D. Date
3 Ear, Nose and Throat Consultants-Pediatric Medical History Form, page 3 Patient Name Review of Systems Please indicate whether your child presently has any of the following symptoms: Yes No Yes No Constitutional Cardiovascular Chills O O Irregular heartbeats O O Fatigue O O Chest pain O O Weight loss/gain O O High blood Pressure O O Daytime fatigue O O Heart failure O O Eyes Heart Murmur O O Eye pain O O Respiratory Watery/itchy/eyes O O Cough O O Blurred vision O O Short of breath O O Ear, Nose, Mouth, Throat Wheeze/Asthma O O Ear pain O O Coughing up blood O O Ear itch O O Gastrointestinal Ear drainage O O Trouble swallowing O O Dizziness/Loss of balance O O Heartburn/burping O O Ear noises/tinnitus O O Genitourinary Hearing Loss O O Troubles with urination O O Post nasal drip O O Musculoskeletal Sinus pain/pressure O O Joint pain O O Loss of smell/taste O O Muscle aches O O Hoarseness O O Endocrine Sore Throat O O Thyroid Overactive O O Throat dryness/tickle O O Thyroid Underactive O O Throat clearing O O Thyroid nodules/lumps O O Skin Hematologic/Lymphatic Rash/itching O O Swollen glands O O Hives O O Night Sweats O O Change in skin/hair O O Bleeding disorder O O Neurological Clotting disorder O O Headaches O O Easy bruising O O Fainting O O Allergic/Immunologic Slurred speech O O Sneezing O O Attention Deficit Disorder O O Itchy Nose/Eyes O O Psychiatric O O Previous allergy tests O O Depression O O Anxiety or panic disorder O O Weight: Height: Reviewed by: M.D. Date
4 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.(ENT/ Allergy) 1021 Main Street, Suite Trade Center, Suite 750 Winchester, MA Woburn, MA Tel: Tel: Fax: Fax: Ear, Nose, & Throat Consultants, Inc. YES NO Did you have any previous MRI scan of ears/head? Date: Did you have any previous CT scan of ears/head? Date: YES NO
5 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:
6 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.
7 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
Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age:
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PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
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Jason Guillot, MD James Connolly, MD Robert Owens, M.D. JJ Martinez, AuD Phone: Fax:
Phone: 985-327-5905 Fax: 985-327-5904 PATIENT INFORMATION DATE: Name: Gender: Male Female Last First Middle (Circle One) Date of Birth: Patient s SS#: Address: Street Address Apt # City State Zip Code
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
FORMS MUST BE COMPLETED IN FULL
1 Nurse Use Only: Height: Weight: Temp: BP: / Pulse: Flu: Pneumonia Mammogram Patient Health Information Patient Name: DOB: Today s Date: How did you hear about us/referring physician: Reason for Today
Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
How did you learn about our office? Patient s Last Name: First: MI: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
Date: / / How did you learn about our office? Patient s Last Name: First: MI: Sex: Male Female Date of Birth: / / Age: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Social
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
Riverview Orthopedics and Sports Medicine 493 Westfield Rd
Dear New Patient, Riverview Orthopedics and Sports Medicine 493 Westfield Rd Noblesville, IN 46060 (317)-770-4100 (Fax: 317-770-4105) Tipton: 765-675-0030 Thank you for choosing our practice for your orthopedic
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX:
I have read and acknowledge all of the above policies associated with Pioneer Cardiovascular Consultants, PC including: (PLEASE INITIAL)
PH:(480) 345-0034; F:(480)345-4033 Patient s Name (Last) (First) (M.I.) SS# Date of Birth / / Marital Status Sex Race :( optional) Ethnicity: (optional) Preferred language: Referring Physician: _ Phone#:
If you are employed, please provide the follow information regarding your employer; Employer Name: Work Address:
Personal Information Patient Registration Form Today s Date: Patients First Name: Date of Birth: / / Social Security #: - - Patients Last Name: Sex: Male / Female Marital Status: Married Single Divorced
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:
Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA 98902 Phone: 453-2010 Fax: 225-6421 Patient Name: Last: First: Middle Initial: Nickname: Sex: M / F Date of Birth:
Caritas Medical Center, LLC
Caritas Medical Center, LLC KIDNEY DISEASE AND HYPERTENSION SPECIALIST 105 NORTH PARK TRAIL SUITE 300 STOCKBRIDGE, GA 30281 OFFICE: 678 284 0800 FAX: 678 284 9299 WWW.CARITASMED.COM DR. LEO OVADJE DR.
PATIENT REGISTRATION FORM
ph. 912.303.0891 x: 912.303.0893 UROGYNsavannah.com 5356 Reynolds Street Suite 301 Savannah, GA 31405 PATIENT REGISTRATION FORM Date Patient Name DOB SSN (Last, First, Middle Initial) Address: (City, Street,
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1 PATIENT NAME DATE OF BIRTH AGE PLEASE PROVIDE THE FOLLOWING MEDICAL INFORMATION TO THE BEST OF YOUR ABILITY: What problems are you here for today? List any allergies
Arizona Retina Associates
PATIENT INFORMATION PLEASE PRINT CLEARLY AND COMPLETE ENTIRE FORM Name FIRST MIDDLE INITIAL LAST SUFFIX (Jr., etc.) Address STREET CITY STATE ZIP Age Birthdate SS# Marital Status S M D W Sex M F Occupation
Greater Austin Allergy, Asthma & Immunology
Greater Austin Allergy, Asthma & Immunology phone: (512) 732-2774 fax: (512) 329-6871 PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Sex Single Married Widowed Divorced Present Address City,
EYES OF THE SOUTHWEST New Patient Information
EYES OF THE SOUTHWEST---------------------New Patient Information PERSONAL INFORMATION (Please Print) Name Date Date of Birth / / Age M/F MailingAddress Street /PO Box City State Zip Code E-MAIL ADDRESS
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
Olathe Chiropractic S. Mur-Len Road - Olathe, KS Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form
Olathe Chiropractic 15930 S. Mur-Len Road - Olathe, KS 66062-8301 Dr. Jeremy Landry Dr. Joseph Anderson New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial
appointment checklist
appointment checklist Dear parents: The staff of Cook Children s Pediatric Gastroenterology (GI) and Nutrition Clinic appreciates your selection of our physicians to serve you and your child s needs. Our
Ronald E. McFarland M.D. PATIENT REGISTRATION AND HISTORY
Ronald E. McFarland M.D. 2021 Church Street, Suite 606 Nashville, TN 37203 PATIENT REGISTRATION AND HISTORY Date: Primary Care Doctor: Name: Sr. Jr. Address: Street City State Zip Code Telephone: Home
Patient / Guarantor Information. Spouse / Parent / Other Information. Insurance. Date:
Patient / Guarantor Information Date: Patient's Legal Name: DOB: / / Address: City: ST: Zip: Home Phone: Cell Phone: Which phone number do you prefer we use? E-mail Address (Required for Patient Portal
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology TODAY S DATE PATIENT S NAME: BIRTHDATE
Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology PATIENT S NAME: TODAY S DATE BIRTHDATE WAS THERE A DOCTOR WHO REFERRED YOU? No Yes If yes, who Who is your Family or Primary care doctor? WHAT are
GENERAL INFORMATION. Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL Phone (954) Fax (954)
Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL 33028 Phone (954)442-7616 Fax (954)442-6234 GENERAL INFORMATION PATIENT NAME: DATE: ADDRESS: CITY: STATE: ZIP: HOME PHONE:
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
VALLEY ENT superior medical care, right in your neighborhood
Please be aware that certain procedures performed in our office are not included under the standard office visit. These procedures are billed separately and in addition to office visit charges. Some insurance
Patient Profile. Gender: [ ] M [ ] F PATIENT INFORMATION. Date of Birth: Age: Name: SSN: Address: Marital Status: [ ] Married [ ] Single [ ] Other:
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Patient Profile PATIENT INFORMATION Name: Address: City,State Zip: Alternate: Address City,State Zip: Home Phone: [ ] preferred Cell Phone: [ ] preferred Work Phone: [ ] preferred Is it ok for ValleyENT
Patient Registration Form
Patient Registration Form Appointment Date/Time Appointment Reason First Name & MI Date of Birth Patient Information Last Name Address Social Security # City State Zip Home Phone Work Phone Cell Phone
Have you recently experienced any of the following?
NAME; DATE: DOB: FEMALE Have you recently experienced any of the following? GENERAL YES NO RESPIRATORY YES NO MUSCULAR/SKELETAL YES NO Change in Activity Apnea Joint Pain Appetite Change (Stop Breathing)