Welcome to the Joslin Diabetes Center at Baptist Health Medical Group Welcome to the Joslin Diabetes Center. We ve assembled this packet to help answer any questions you might have. Please bring your insurance card and a photo I.D. to all appointments with us. Your picture will also be taken at registration. If your insurance company requires a referral for you to see a specialist or for the selfmanagement classes, it is your responsibility to call them and get a referral number. If you have questions about your coverage, please call your insurance carrier. We will be unable to see you if you do not bring the referral number to the appointment or call it in before your visit. This may force you to reschedule and therefore delay your visit. Please obtain the referral number in advance if your insurance requires one. If you have questions that are not answered in this packet, please feel free to call us at (812) 949-5700 or toll free at 1-888-773-6447. 2019 State Street New Albany, IN 47150 BaptistHealthFloyd.com/Joslin 142046 (10/16) BHF (812) 949-5700 office (812) 949-5791 fax (812) 949-5979 fax (for blood sugars) 1-888-77-FMHHS toll free joslin@bhsi.com
2019 State Street New Albany, IN 47150 (812) 949-5700 1 ST VISIT QUESTIONNAIRE Please complete and bring with you to your first visit. Name: DOB: Appointment Date: Family Doctor: First Name Last Name Phone Number Referred by Family Doctor? Yes No Other (Specify) Ok to send them a letter? Yes No Reason for visit: Diabetes Management Thyroid Problem Other If Diabetes: Date of Diagnosis: Have you ever had formal diabetes education? Yes No If yes, where? When? Do you have a meter? Yes No If yes, what kind? If yes, how old, and how often do you test your blood sugars? Last eye doctor visit: Doctors Name: List Medications: Pharmacy: Pharmacy Number: Over the counter meds: Aspirin: Yes No Vitamin: Yes No Other: Past History Yes No Diagnosis Thyroid Disease High Blood Pressure Cataracts Glaucoma Heart Attack High Cholesterol Other: List Type and Date: Pregnancies: How many? Deliveries? Breast Feed: Yes No Biggest baby weight: Surgeries: List Type and Date Allergies & Type of Reactions No Known Medicine Allergies If allergic, list medicines and type of reaction:
2 Name: Yes No Family History Who Diabetes Heart Disease Stroke High Blood Pressure High Cholesterol Thyroid Disease Cancer Type Other: Social History Single Married Divorced Widow Live with: Sexually Active: Yes No Work: Hours: Retired: Yes No Smoker: Yes No Alcohol: Yes No How Much: Flu Shot: No Yes When: Pneumonia Vaccine: No Yes When: Tetanus Shot: No Yes When: Do You Have: Yes No How Long Yes No How Long Fever Wt. Loss # Headaches Wt. Gain # Blurred Vision Irritability Double Vision Tremors Passing out Episodes Sweating Shortness of breath Hot Flashes Dizziness Vaginal Discharge Erection problems Too Hot Dry Mouth Too Cold Thirst Snoring Increase Urination Night Time Urination Burning upon Urination Increase Facial Hair Nausea Hair Loss Vomiting Other Bloating Diarrhea Constipation Office Use Only Swelling Date Reviewed: MD Signature: Pain in feet Numbness hands Numbness feet
Patient Information Last Name: Maiden Name First Name: Middle: Address: City: State: Zip: County: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Email Address: omale ofemale DOB: / / State of Birth: SS#: - - Primary Care Physician: Preferred Pharmacy/Location: Marital Status: osingle omarried odivorced owidowed oseparated oother Race: Ethnicity: ohispanic/latino onon-hispanic/latino oother/undetermined Employer: _ Address: City: State: Zip: Emergency Contact: Relationship: Phone: ( ) Type of phone: ohome owork ocell Address: City: State: Zip: Spouse s Name: Spouse s DOB: / / Social Security Number: - - Spouse s Employer: Phone: ( ) How did you hear about us? Your Email address: How would you like us to contact you? oletter ophone Call oemail RESPONSIBLE PARTY INFORMATION (IF DIFFERENT FROM PATIENT INFORMATION) Full Name: omale ofemale DOB: / / SS# - - Relationship to Patient: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Employer: _ INSURANCE INFORMATION Primary Insurance: Policy Holder: Date of Birth: / / Relationship: Insurance ID Number: Group Number: Secondary Insurance: Policy Holder: Date of Birth: / / Relationship: Insurance ID Number: Group Number: I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to release medical information to my insurance company to secure payment of benefits. I also authorize the use of this signature on all insurance submissions and as authorization for payments to be sent to Baptist Health Medical Group. This signature authorizes release of medical records to any physicians or health care facility when referred of requested by them for continuity of care. I voluntarily consent to medical care including the routing of diagnostic testing, surgical procedures and additional medical treatment. Responsible Party Signature: Relationship: Date: 161001 (10/16) BHF
HIPAA Contact Release Form Dear Patient, In order to help us stay within the guidelines of HIPAA, please list below any person/persons that you authorize us to disclose information to regarding your Protected Health Information, including billing information. (You do not need to list any of your doctors.) Name Relationship Phone 1. Home/Cell 2. Home/Cell 3. Home/Cell 4. Home/Cell Do we have your permission to leave information on your answering machine or phone s voicemail when you are not available? Yes No Patient s Name (Please Print) Date of Birth Patient s (or Guardian s) Signature Date 161012 (10/16) BHF