Patient: DOB: MR# Home Phone: Alternate Phone: Referring MD: Primary MD: Diagnosis Age: Gender: Weight: Height: BSA BMI
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1 Patient: DOB: MR# Date of Referral Date of Evaluation Home Phone: Alternate Phone: Referring MD: Primary MD: Diagnosis Age: Gender: Weight: Height: BSA BMI Blood Type(#1) #2 ALLERGIES: DATE: _ Transfusions: Y / N (Date ) Symptoms Chest Pain Y / N Palpitations Y /N SOB Y / N Syncope Y / N PND Y / N Claudication Y / N NYHA Class I / II / III / IV AHA Stage A / B / C / D PRA: Class I: Class II: Crossmatch Y/N DATE: Past Medical / Surgical History Cardiac Surgery Y / N Date(s) LVAD Y/ N Date Type RVAD Y / N Date Type MI Y / N Dates(s) Description PTCA Y / N Date(s) Site Sudden Death Y / N Date(s) Arrhythmias Y / N Date(s) Type Treatment Afib Y / N Date(s) Treatment_ ICD Y / N Date Model #s_last fired Pacemaker Y / N Date Model# Hypertension Y / N Diagnosed Diabetes Y / N NIDDM / IDDM Diagnosed COPD Y / N PUD Y / N Hepatitis B / C Diagnosis Date HIV AIDS Malignancy Y / N Type Date Diagnosed Treatment Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise All rights and credits to this document will be credited to the author and donating insitution.
2 PAD Y / N CVA / TIA Y / N Date(s) Residual Pregnancies Y / N Gravida Para Other PMH ( including # of hospitalizations recently) General Surgery Social History Tobacco History Y / N Active Y / N Pack/ Year Last Use Alcohol History Y / N Active Y / N Amount Last Use Illicit Drug History Y / N Active Y / N Type Last Use Employed Y / N Occupation Disabled / Retired Y / N When Family History Mother Father_ Other Studies Date MVO2 RER Duration Date PFT FEV1 / % FVC / % FEV1/FVC DLCO / % Date ECG Rhythm QRS duration BBB Date Echo EF % LVIDd MR 0 / 1 / 2 / 3 / 4 RV Fxn - NL / M / Mod / Severe Valves Comment_ Date CXR Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise Date Doppler Studies Carotids: Lower Extremity All rights and credits to this document will be credited to the author and donating insitution. Date Abdominal Ultrasound Date Gastric Emptying Date LHC
3 Cath Date(s) Pressors RAm PAs PAd PAm PCWP C.O. C.I. PVR BP/ HR labwork BUN Creatinine AST ALT T. Bili Alk Phos LDH TP Albumin CMV IgG CMV IgM Toxo IgG Toxo IgM RPR HbsAg HbsAb HbcAb Hep A Hep C HIV Cholestrol Trig HDL Chol:HDL Fe TIBC %Sat Ca Mg PT INR PTT TSH Glucose HgA1C PSA Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise All rights and credits to this document will be credited to the author and donating insitution. Na K U/A WBC HCT HGB CPK 24 Hour Creatinine Clearance Protein Date Mammogram Date PAP Smear Date Colonoscopy Date Panorex Dental X-Rays
4 Consults Renal (Date ) Hepatology (Date ) Pulmonary (Date ) Other (Date ) Presented to Selection Committee: Date(s) Comments / Follow up: Candidate for OHT Y / N Candidate for VAD Y / N Insurance Status: Cleared for OHT Y / N Date Cleared for VAD Y / N Date Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise All rights and credits to this document will be credited to the author and donating insitution. Listed Outcome: Reason Date of Listing (UNOS) Too Well Comorbidity Declined Non-Medical Unable to determine Refused Status at this time Further Evaluation Needed Evaluation Coordinator Date Attending Physician Date
5 Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise All rights and credits to this document will be credited to the author and donating insitution.
6 Use of this document is strictly voluntary and solely at your own risk. You release MyLVAD, the autor and donating institution from any and all legal claims that arise All rights and credits to this document will be credited to the author and donating insitution.
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Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX
PATIENT INFORMATION First Name MI Last Name Date of Birth Age: Social Security # Race Ethnicity: Sex: Female / Male Marital Status: S M W D Email Address: Mailing Address City State Zip Physical Address
First, MI, Last Name: Mailing Address: City: State: Zip: Home Phone: Cell: SSN: Referring Provider: Primary Care Provider:
Glenn L. Keiper Jr. MD, Ralph G. Peterson PA-C Jonathan D. Sherman MD, Jason A. Kocian PA-C 1410 Oak Street, Suite 200, Eugene, OR 97401 Phone: 541-485-2357 Fax: 541-485-2358 Date: First, MI, Last Name:
ELECTRONIC APPLICATION WORKSHEET
PROPOSED INSURED Last & First Name: M F Last Name at Birth: Complete Address: Date of Birth: Conserve age Tel: Work Tel: Birthplace: Since When in Canada: SIN: Legal Status: Occupation: Since: Mandatory
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $3,400 The maximum out-of-pocket limit applies to all
Welcome to the Aker Kasten Eye Center!
ALAN B. AKER, MD ANN G. KASTEN AKER, MD JILL F. RODILA, MD VITO J. GUARIO, OD KELLI F. WOLPER, OD Welcome to the Aker Kasten Eye Center! On behalf of the doctors and staff, we would like to thank you for