Patient Information Sheet
Date ____________________________________
Last Name _________________________ First _______________________ Middle _________
Sex: Female Male SSN: ___________________________ Date of Birth _____________
Street Address _________________________________________________________________
Phone Numbers: Home ______________________________________________________
Work ______________________________________ Ext. ____________
Cell phone __________________________________________________
Emergency __________________________ Name __________________
Employer: _____________________________________________________________________
Occupation: ________________________________________________ Retired
Marital Status: Married Single Divorced Other
If married, name of spouse: _________________________________________________
Spouse’s Date of Birth: ____________________ Spouse’s SSN: ___________________
Spouse’s Employer _______________________________________________________
If surgery is needed, which hospital do you prefer?
Western Baptist
Do you want to be listed as a “privacy patient”? yes no
Information may be
released to the following: (i.e. spouse,
son, daughter, parent, etc.)
Name: _____________________________________ Relation: ____________________
Name: _____________________________________ Relation: ____________________
Name: _____________________________________ Relation: ____________________
Name: _____________________________________ Relation: ____________________
Name of referring physician ______________________________________________________
Have you ever been here before? Yes No If yes, when was your last visit? _________
History of Present Illness:
Why are you here today? _________________________________________________________
When did this problem start? ______________________________________________________
What treatment have you had for this problem? _______________________________________
______________________________________________________________________________
Allergies:
1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________
Are you allergic to
Latex? Yes
No
Medications and Dosages: (Including Herbal medications) We will be happy to copy a list if you have one.
1) ___________________________________ 6) _________________________________
2) ___________________________________ 7) _________________________________
3) ___________________________________ 8) _________________________________
4) ___________________________________ 9) _________________________________
5) ___________________________________ 10) _________________________________
Past Surgical History: Please lest all past surgeries and the year.
1) ____________________________________________________ Year _____________
2) ____________________________________________________ Year _____________
3) ____________________________________________________ Year _____________
4) ____________________________________________________ Year _____________
Please describe any anesthesia problems you may have had: __________________________
______________________________________________________________________________
Family Medical History: Please list immediate family members with any of these problems.
Diabetes ______________________________________________
Breast cancer __________________________________________
Other cancer ___________________________________________
Heart problems _________________________________________
High blood pressure ______________________________________
Patient Social History:
Use of alcohol: Never Rarely Moderately Daily
Use of tobacco: Never Previously but quit Current packs per day ________
How long have you smoked? ___________________________________
Use of drugs: Never Type/frequency __________________________________
Excessive exposure at home or work to: Fumes Dust Solvents Noise
Please check all that
apply to you:
GENERAL KIDNEYS
Good general health lately Dribbling or incontinence
Recent weight change Frequent urination at night
Fever Frequent infections
Fatigue Blood in urine
EYES Female – Still having periods
Eye disease or injury Male – Testicle pain
Wear glasses or contacts Sexually transmitted disease
Blurred or double vision MUSCLES/BONES
Glaucoma Arthritis
EARS/NOSE/MOUTH/THROAT Difficulty walking
Hearing loss Back pain
Ringing in ears Leg pain with walking
Ear aches or drainage Osteoporosis
Nose bleeds SKIN/BREAST
Chronic sinus problems Skin rash or moles removed
Mouth sores Varicose veins
Difficulty swallowing Breast pain
Swollen glands in neck Breast lump/cyst
HEART Breast discharge
High blood pressure NERVES
Heart attack Frequent headaches
Chest pain Dizziness or light headed
Congestive heart failure Seizures
Palpitations or irregular beats Head injury
Mitral valve prolapse or murmurs Parkinson
Short of breath when walking Stroke or paralysis
Swelling in feet, ankles, or hands Alzheimer
LUNGS Numbness
Chronic or frequent coughs PSYCHIATRIC
Spitting up blood Memory loss or confusion
Prior pneumonia Anxiety or depression
Asthma or wheezing ENDOCRINE
STOMACH Hormone problem
Loss of appetite Thyroid disease
Heart burn or indigestion Diabetes
Nausea or vomiting BLOOD
Abdominal pain Bleeding or bruising tendency
History of ulcers or diverticulitis Anemia
Change in bowel movements Phlebitis
Rectal bleeding or blood in stools Past blood transfusion – date ____
Grogan & Howard, PSC
I hereby instruct and direct my current insurance company to pay by check made out and mailed to:
Grogan & Howard, PSC
WBH DOB 2,
or
If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it to the same address listed above for the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
A photocopy of this Assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, attorney, or any other provider involved in this case.
I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
__________________________________________ Date ___________________
Signature of Policyholder
__________________________________________ Date ___________________
Signature of Claimant (if other than Policyholder)