Southern Oregon Wellness Clinic 2921 Doctors Park Drive Phone (541) Fax (541)

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Barnaby Cummings
5 years ago
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CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually

1 CONDITIONS OF SERVICES RENDERED FINANCIAL AGREEMENT: I agree, whether I sign as agent or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account with Southern Oregon Wellness Clinic in accordance with the regular rates and terms. Should the account be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorney s fees and collection expenses. ASSIGNMENT OF INSURANCE BENEFITS: I authorize, whether I sign as agent or as patient, direct payment to Southern Oregon Wellness Clinic of any insurance benefits otherwise payable to or on behalf of the patient for the visit or for these outpatient services at a rate not to exceed Southern Oregon Wellness Clinic s actual charges. I understand that I am financially responsible for charges, deductibles, and co-insurance not covered by insurance. HEALTH PLAN OBLIGATIONS: Southern Oregon Wellness Clinic maintains a list of health plans with which it contracts. Southern Oregon Wellness Clinic has no contract, expressed or implied, with any plan that does not appear on that list. The undersigned agrees that he/she is individually obligated to pay the full charges of all services rendered to him/her by Southern Oregon Wellness Clinic if he/she belongs to a plan, which does not appear on the above- mentioned list. RELEASE OF INFORMATION: I authorize Southern Oregon Clinic to release any information necessary to provide medical treatment to me, allow Southern Oregon Wellness Clinic to bill and be paid for services they provide. I understand that releasing information for any reason other than those listed above requires a separate authorization by me. I also understand that I have the right to request restrictions on the use of my health information, but Southern Oregon Wellness Clinic is not obligated to honor that request unless required to do so by State or Federal regulations. This consent shall be effective as long as necessary to obtain payment. The Terms and conditions of this agreement are not binding until the patient receives care and treatment from Southern Oregon Wellness Clinic. The undersigned certifies that he/she had read the foregoing, received a copy thereof, and is the patient, the patient s legal representative, or is duly authorized by the patient as the patient s general agent to execute the above and accept its terms. DATE: PRINT NAME: SIGNATURE: (PATIENT/PARENT/CONSERVATOR/GUARDIAN) If signed by other than patient, indicate relationship: **** ATTENTION PATIENTS **** Scheduled appointments that are not cancelled 24 hours in advance will incur an annoyance fee of: $25.00

2 PATIENT ACKNOWLEDGEMENT FORM Receipt of Joint Notice of Privacy Practices By my signature below, I hereby acknowledge that I have received a copy of Southern Oregon Wellness Clinic s Notice of Privacy Practices. Southern Oregon Wellness Clinic is permitted to use or disclose my health information to carry out treatment, payment or health care operations. Health information means any and all information relating to health care services provided to me, including information related to services provided to me prior to the date I sign the acknowledgement form. I understand the Southern Oregon Wellness Clinic s Notice of Privacy Practices explains the types of uses or disclosures that Southern Oregon Wellness Clinic may make and my rights with respect to my health information. I understand that if I have any questions or concerns about this Notice, I may contact the Office Manager at the telephone number listed below. I further understand Southern Oregon Wellness Clinic may change the terms of the Notice of Privacy Practices from time to time, and that I may contact the Office Manager to obtain a revised version of the notice at any time. Patient s Printed Name: Patient s DOB: Signature of Patient: Date: Signature other than patient: Date: If signed by other than patient, indicate relationship: You may contact our office regarding your privacy by calling

3 Please Print Patient Registration Form Patient name Date of birth Mailing address City State Zip Home Phone Cell Phone SSN# Male Female Single Married Divorced Widowed Employer Phone Is it okay to leave medical information on your voic if we are unable to reach you? Yes No Spouse s name Date of birth Spouse s SSN# - - Phone Spouse s Employer Phone Emergency Contact Name Relationship Phone Medical Insurance Information Primary Insurance ID Number Group Number Insured name Date of birth Secondary Insurance ID Number Group Number Insured name Date of birth

4 Patient Name: DOB: Date: HEALTH CONCERNS Please list your health concerns, in order of importance: 1) 4) 2) 5) 3) 6) When was the last time you felt truly well? What do you think is wrong with your health? FAMILY HISTORY Mark with an X or appropriate response: Mother Father Brother Sister Child Spouse Age (if living) Health (G=good, P=poor) Age at death (if deceased) Alcoholism Anemia Arthritis Asthma/ Allergies/ Hives Cancer Cataracts/ Glaucoma Diabetes Epilepsy Gallbladder Disease Heart Disease High Blood Pressure Kidney Disease Liver Disease Mental Illness Stroke Thyroid Problems Other Other

5 HOSPITALIZATION/ SURGERIES/ ACCIDENTS Please list any hospitalization or surgeries: Please list major accidents: Have you ever had a concussion? YES NO If yes, When? What happened? X-RAYS AND SPECIAL STUDIES Please list any X-rays, CT Scans, MRIs or other studies you have had in the past: Reason Reason Reason ALLERGIES AND SENSITIVITIES Please list all known drug allergies: DRUG RXN SEVERITY Please list any known food allergies, intolerance's or sensitivities: FOOD RXN SEVERITY Please list any environmental allergies: ALLERGEN RXN SEVERITY Any known toxic exposures? YES NO If yes, explain:

6 PRESCRIPTIONS Please list all prescription and over the counter drugs that you currently take. DRUG DOSAGE REASON SUPPLEMENTS Please list all supplements that you currently take. SUPPLEMENT DOSAGE REASON How often do you take antibiotics? Have you ever taken antibiotics for longer than 1 month at a time? YES NO If yes, why? LIFESTYLE OVERVIEW: Interests and Hobbies: Tobacco use: Never Smoked Former Smoker Current Smoker Packs Per Day? Do you exercise? YES NO Do you enjoy your work? YES NO Take vacations? YES NO Average 6-8 hours of sleep per night? YES NO If no, how much? Do you drink coffee? YES NO Soda? YES NO Beer/ Wine/ Spirits? YES NO How many ounces of water do you drink per day? Have you been treated for substance abuse/ alcoholism? YES NO If yes, when? Married: YES NO Children? YES NO If yes, ages:

7 REVIEW OF SYSTEMS GENERAL Height: Current Weight: lbs. Weight 1 year ago: lbs. Maximum Weight: lbs. When? Rate your daily energy level on a scale of 1-10 (Please circle): Ext. Low Low Moderate High Rate your daily stress level on a scale of 1-10 (Please circle): Low Moderate Extreme Please circle Y=Yes, present condition. N=No, never had the condition. P=Past problem. HEAD Headaches Y P N Head Injury Y P N Migraines Y P N EARS Ringing Y P N Earaches Y P N Dizziness Y P N Impaired Hearing Y P N EYES Blurred vision Y P N Eye pain Y P N Spots in eye Y P N Cataracts Y P N Glaucoma Y P N Glasses/ Contacts Y P N Tearing/dryness Y P N Double vision Y P N NOSE/ SINUSES Stuffiness Y P N Hay Fever Y P N Loss of Smell Y P N Nose bleeds Y P N Sinus problems Y P N Frequent colds Y P N MOUTH/ TROAT Hoarseness Y P N Frequent sore throat Y P N Sore Lips/ tongue Y P N Gum problems Y P N Dental problems Y P N

8 Please circle Y=Yes, present condition. N=No, never had the condition. P=Past problem. NECK Lumps Y P N Swollen Glands Y P N Swollen glands Y P N Pain or stiffness Y P N Goiter Y P N PERIPHERAL VASCULAR Anemia Y P N Leg pain Y P N Cold hand/feet Y P N Easy bruising Y P N Blood clots Y P N Varicose veins Y P N RESPIRATORY Asthma Y P N Cough Y P N Sputum Y P N Wheezing Y P N Bronchitis Y P N Pneumonia Y P N Emphysema Y P N Pleurisy Y P N Tuberculosis Y P N Spitting up blood Y P N Difficulty breathing Y P N Pain with breathing Y P N Shortness of breath Y P N At Night Y P N Lying down Y P N CARDIOVASCULAR Heart disease Y P N Heart murmur Y P N Angina Y P N Chest Pain Y P N Ankle swelling Y P N Blood clots Y P N High blood pressure Y P N Low blood pressure Y P N Rheumatic Fever Y P N Fainting Y P N GASTROINTESTINAL Heartburn Y P N Difficulty swallowing Y P N Abdominal pain Y P N Cramps Y P N Belching/ passing gas Y P N Nausea/ vomiting Y P N Change in appetite Y P N Change in thirst Y P N Diarrhea Y P N Constipation Y P N Gallbladder disease Y P N Ulcers Y P N Vomiting Blood Y P N Jaundice Y P N Liver Disease Y P N Black Stool Y P N Hemorrhoids Y P N Blood in stool Y P N Number of bowel movements per day? is this a change? YES NO URINARY Incontinence Y P N Kidney stones Y P N Frequent infections Y P N Frequency at night Y P N Painful urination Y P N Straining to urinate Y P N MUSCULOSKELETAL Joint Pain Y P N Arthritis Y P N Muscle Spasm Y P N Sciatica Y P N

9 Please circle Y=Yes, present condition. N=No, never had the condition. P=Past problem. SKIN Rashes Y P N Acne, Boils Y P N Itching Y P N Eczema Y P N Color changes Y P N Psoriasis Y P N Lumps Y P N NEUROLOGICAL Loss of consciousness Y P N Muscle weakness Y P N Loss of memory Y P N Paralysis Y P N Vertigo or dizziness Y P N Loss of balance Y P N Numbness/ tingling Y P N Seizures Y P N ENDOCRINE Hypothyroid Y P N Hyperthyroid Y P N Excessive hunger Y P N Excessive thirst Y P N Cold intolerance Y P N Heat intolerance Y P N Diabetes Y P N Night sweats Y P N Loss of hair Y P N Autoimmune disease Y P N MENTAL/ EMOTIONAL Mood swings Y P N Anxiety Y P N Clinical depression Y P N Nervousness Y P N Tension Y P N Panic Attacks Y P N FEMALE REPRODUCTIVE Age of first menses Tender breasts Y P N Age of last menses Menopausal Sexual difficulties Y P N Length of Cycle days Breast Lump(s) Y P N Duration of menses days Endometriosis Y P N Date of last annual exam Fertility issues Y P N Are you sexually active Y P N Venereal disease Y P N Birth control Y P N Irregular cycle Y P N Type of birth Control Abnormal Pap Y P N Number of pregnancies Nipple discharge Y P N Number of live births Ovarian cysts Y P N Number of miscarriages Cervical dysplasia Y P N Painful menses? Y P N Mid cycle bleeding Y P N Heavy flow? Y P N PMS Y P N Menopause symptoms Y P N Self-breast exams Y P N MALE REPRODUCTIVE Hernias Y P N Testicular pain Y P N Testicular masses Y P N Are you sexually active Y N Venereal disease Y P N Impotence Y P N Premature ejaculation Y P N Prostate disease Y P N Discharge or sores Y P N Fertility difficulties Y P N Birth control use Y P N Type?

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address: PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail: