J&J Medical 5920 North La Cholla Blvd Suite 150

Tucson, Arizona 85741

Phone (520) 547-5836

Fax (520) 547-5841

Welcome to J&J Medical. Please take a moment to review our office policies. If you have any questions,

please address them with our Site Coordinator.

1. Patients need to arrive 15 minutes prior to their scheduled appointment time. This is to allow

for verification of insurance and completion of all necessary paperwork. We reserve the right to

ask you to reschedule if you are more than 5 minutes late.

2. Please note annual mammography is recommended after the age of 40. Dexa scans and

colonoscopies are recommended after the age of 50 or sooner based on family history.

3. If there is a need to cancel your appointment, please do so 24 hours in advance. There will be a

$25.00 fee if you do not show for your appointment or if you do not give 24 hours’ notice when

canceling.

4. Co-pays are due at the time of services as dictated by your insurance. We do not bill co-pays.

We will accept cash, check, Visa, Mastercard and Discover. We do not accept American Express.

5. To assist us in providing good medical care, it is very helpful if you bring in an updated list of

medications and doses to each visit. If we are managing your diabetes or hypertension, bring in

your readings.

6. Please provide us with at least two phone numbers that we can contact you at regarding your

healthcare.

7. There is a $25.00-$50.00 charge for filling out forms for FMLA and disability. The price is based

on the amount of time required to complete the forms. There is no charge for filling out

physical or MVD handicap forms.

8. Contact your pharmacy for all prescription refill requests. Please allow 48 hours for prescription

refills. Please note, any prescriptions that are called in after hours will not be authorized until

the following business day. Medications prescribed by specialists must be refilled by the

specialist that prescribed them.

Office Hours

Monday, Tuesday, Thursday 7:00 – 5:00

Wednesday 9:00 – 5:00

Friday 8:00 – 5:00

All of our staff members are trained to assist you in obtaining the best care possible and to do so with

courtesy and compassion. We strive to provide the best professional care possible. In turn, our

provider expects our patients to treat our staff with courtesy and respect. Abuse of our staff will not be

tolerated and may result in termination of your care at J&J Medical.

Name:_________________________ DOB:____________ Date:____________________ MRN:___________

HEALTH QUESTIONNARE GENERAL

By what name do you wish to be called? _______________________________Marital Status S □ M□ W□ D□

Where were you born? ____________________. Do you live in Arizona all year? □ YES □ NO

Did you move here for health reasons? Yes□ No□

What is your occupation? __________________________________________How long? ________________

PERSONAL HABITS

Tobacco Yes □ No □ Quit □ When__________ Yes □ No□ Alcohol: How many? _______drinks per week

Cigars □ Cigarettes □ Pipes □ Yes □ No □ Coffee: How many? __________ Cups per day

How much? __________ How long? ______ Years Yes □ No □ Regular Exercise: How often? ___________

MEDICATIONS

*Please write, name of medication, dose and frequency or attach medication list. Name & Reason Name & Reason

________________________ ________________________

________________________ _________________________

_________________________ _________________________

_________________________ _________________________

□ Other Drugs (include marijuana, etc.) _____________________________________________

ALLERGIES (if you are allergic to any drugs, foods, pollens, etc, describe effect)

Allergic To: Effect:

____________________________________ __________________________________________

____________________________________ __________________________________________

VACCINATIONS (Check those you have had and write in dates below)

□Tetanus________________ □Polio _________________ □German Measles ______________

□Diphtheria _____________ □Flu ___________________ □Zostavax (shingles) ____________

□Mumps _________________ □Pneumonia/ Prevnar 13 _________ □Other _______________________

PERSONAL HISTORY (Check those you have had)

□High Blood Pressure □Kidney Trouble □Mental Illness □Hay Fever, Asthma

□Sugar Diabetes □Liver Trouble □Suicide Attempts □Breathing Trouble

□Heart Trouble □Anemia □Epilepsy □Valley Fever

□Stroke □Arthritis □Excess Drugs □Cancer

PRIOR OPERATIONS/ PROCEDURES (e.g. Colonoscopy, mammography, bone density, hysterectomy,

and mastectomy) list all dates. __________________________________________________________________________________________

__________________________________________________________________________________________

FAMILY HISTORY (Include parents and grandparents)

□High Blood Pressure □Kidney Trouble □Mental Illness □Hay Fever, Asthma

□Sugar Diabetes □Liver Trouble □Suicide Attempts □Breathing Trouble

□Heart Trouble □Anemia □Epilepsy □Valley Fever

□Stroke □Arthritis □Excess Drugs □Cancer

Family

History

Age State of Health or

Cause of Death

Check if

Deceased

Family

Member

Age State of Health or

Cause of Death

Check if

Deceased

Mother Children

Father Husband/

Wife

Sister/ Brother

Name:_________________________ DOB:____________ Date:____________________ MRN:___________

IF YOU HAVE OR HAVE HAD ANY PROBLEMS IN THE FOLLOWING AREAS. IF IS YES, CHECK

PROBLEMS AND GIVE DETAILS OF EACH SECTION BELOW.

GENERAL □Fever □Sweats □Chills □Headaches □Weight Change □Faintness

□Excess Tiredness, Fatigue □Nose □Throat □Sinuses

□ Other: __________________________________________________________________________________

HEART, LUNGS ______________________________________________________

□Last Chest x-ray- When? _____________________ □Last EKG- When? ___________________

□Cough, Wheezing or Asthma □Chest Tightness, Pain

□Coughing Blood □High Blood Pressure

□Irregular Heartbeat □Shortness of breath □Other: ___________________

BREAST □Pain □Lumps □Regular Self-Exam □Prior breast surgery

STOMACH, DIGESTION

□Constipation □Indigestion

□Bloody or Black stools □Vomiting

□Rupture or Hernia □Diarrhea

□Hemorrhoids □Change in Bowel Habits

Other: ____________________________________________________________________________________

KIDNEYS, URINATION

□Kidney or Bladder Infection □Frequent Urination

□Kidney Stone □Blood in the urine

□Pain with Urination □Urination at night

Other:____________________________________________________________________________________

INTEGUMENTARY □Skin □Hair □Nails

SKELETAL □Bones □Joints □Muscles

NERVERS, EMOTIONS

□History of child abuse □Psychiatric Care or Counseling

□Convulsions □Suicide Attempts

□Depression □Sleep Disorders or Problems

□Excess Anxiety □Problems with Family Relationships?

SURGERY Have you ever been advised to have a surgical operation which you have not undergone?

□Yes □No If is yes, explain ________________________________________________________________

Are you satisfied with your sexual relationships? □Yes □No

Do you have any problems or questions about sex that you would like to discuss with your doctor? □Yes □No

MEN ONLY

□Male surgeries? Type_________________________ □Weak or slow urine stream

□Pain or lump in testicles □Discharge from penis

Difficulty with Erection □Discharge from penis

□Sexually Transmitted Disease

WOMEN ONLY

Length of Periods______ days Date of last Period______________ Age of menstruation began_____________

Last Pap and Pelvic____________________ □Are you pregnant? __________________

□Pain or Bleeding with intercourse □Bleeding between periods __________________

□Irregular Periods, Severe Cramps □Using Birth Control? Type: _________________

□Female Surgery? Type ____________________ □Sexually transmitted Disease

□Current Vaginal Infection □Other: ___________________________

Arizona Community PhysiciansPatient Information

/ /

FIRST NAME LAST NAME

HOME PHONE

ADDRESS CITY STATE ZIP

CELL PHONE

PRIMARY CARE PHYSICIAN PREVIOUS NAMESTUDENT? FT OR PT

EMPLOYER NAME EMPLOYER PHONEEMPLOYER ADDRESSBilling Information

(If different than patient)

FIRST NAME MI LAST NAME ADDRESS CITY STATE/ZIP PHONE

EMERGENCY PHONE# EMERGENCY CONTACT NAME

Primary Insurance Information

INSURANCE NAME MEDICAL CLAIMS ADDRESSEFFECTIVE DATE

GROUP ID# POLICY ID#

CO-PAY AMOUNT

SUBSCRIBER NAME (POLICY HOLDER)

RELATIONSHIP OF PATIENT TO SUBSCRIBER

SELF SPOUSE CHILD OTHER

SUBSCRIBER DATE OF BIRTH SUBSCRIBER SEX SUBSCRIBER SSN#

SUBSCRIBER EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE#

Secondary Insurance Information

alcohol abuse and HIV/AIDS for the purpose of carrying out treatment, payment and healthcare operations. I have been provided or offered a copy of Arizona Community Physicians' Privacy Statement. I assign all medical and/or surgical benefits including major medical benefits to Arizona Community Physicians for services rendered. By signing this form I am confirming that the above demographic and insurance information is current and correct. If the information is not correct I understand I will be held responsible for all charges incurred in today's visit.

The effective period of this authorization is from today's date to a future date, when I am no longer a patient of the Arizona Community Physicians, P.C. group or am deceased.

PERSON GIVING CONSENT RELATIONSHIP IF NOT THE PATIENT DATE

Form #101

/ RELATION

SUBSCRIBER ADDRESS (if different than patient) SUBSCRIBER PHONE (if different than patient)

/ /

MIDDLE

INSURANCE NAME MEDICAL CLAIMS ADDRESSEFFECTIVE DATE

GROUP ID# POLICY ID#

CO-PAY AMOUNT

SUBSCRIBER NAME (POLICY HOLDER)

RELATIONSHIP OF PATIENT TO SUBSCRIBER

SELF SPOUSE CHILD OTHER

SUBSCRIBER DATE OF BIRTH SUBSCRIBER SEX SUBSCRIBER SSN#

SUBSCRIBER EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE#

SUBSCRIBER ADDRESS (if different than patient) SUBSCRIBER PHONE (if different than patient)

/ /

By signing this form, I am consenting to Arizona Community Physicians' use and disclosure of my Protected Health Care Information, including information related to psychiatric care, drug and

DOB SEX MARITAL STATUS EMAIL RACE (o p t i o n a l )

Name:____________________________

Occupation: _______________ Age: _________

COMPLAINTS: Please circle the appropriate number 1-5 according to severity: 1 = mild, 5 = very

Severe, 0 = no problem:

Nasal discharge 0 1 2 3 4 5 Chronic fatigue 0 1 2 3 4 5 Nasal obstruction 0 1 2 3 4 5 Food intolerance 0 1 2 3 4 5 Watery or itchy eyes 0 1 2 3 4 5 Frequent sinus or ear infection 0 1 2 3 4 5 Sneezing 0 1 2 3 4 5 Frequent colds or sore throats 0 1 2 3 4 5 Wheezing 0 1 2 3 4 5 Learning disability 0 1 2 3 4 5

Cough 0 1 2 3 4 5 Poor memory or concentration 0 1 2 3 4 5 Itching 0 1 2 3 4 5 Hyperactivity 0 1 2 3 4 5 Eczema 0 1 2 3 4 5 Abdominal gas or cramping 0 1 2 3 4 5 Hives 0 1 2 3 4 5 Arthritis or muscle aching 0 1 2 3 4 5 Headache 0 1 2 3 4 5 Asthma 0 1 2 3 4 5

Other symptoms:

Which (if any) foods cause you any problems?

________________________________________________________________________

In what year did your allergies start? ____________________________________________

How many months of the year do you have allergies?

___________________________________________________________________

Have you been allergy tested before? __________ If yes, did you receive desensitization shots?

______________________________________

What prescription medications have you tried for allergies? How long did you use them?

1. ___________________________________________For how long? ______________________

2. __________________________________________ For how long? _____________

3. __________________________________________ For how long? _____________

Does any medication give you relief of symptoms?

_____________________________________________________________________

List any animals you have in or around the home_________________________________________________

Who else in your family has allergies?__________________________________________________

How did you hear about our office? (Be specific. If a newspaper, please give

name)________________________

Arizona Community Physicians, P.C. 

Release of Information Form  

                               Account #_____________ 

 

Patient Name __________________________________ DOB________________ Date_______________ 

The confidentiality of our patients’ medical information is very important to us. We understand there 

may be circumstances in which a family member or close friend needs access to your health 

information, or to the health information of someone under your care. 

Please list the names and phone numbers of anyone who has your permission to have access to your  

medical records,  or to your dependents medical records. This information is not limited to but includes 

appointments, billing information and test results. 

Spouse’s Name ___________________________________Contact Number_______________________ 

Child’s Name_____________________________________ Contact Number______________________ 

                       ______________________________________Contact Number_______________________ 

Parent’s Name____________________________________ Contact Number_______________________ 

                           ____________________________________Contact Number______________________ 

Other’s Name ____________________________________ Contact Number_______________________ 

                          _____________________________________Contact Number_______________________ 

DO NOT RELEASE Information to the following people: ________________________________________ 

_____________________________________________________________________________________ 

Please check if applicable: 

_______  I give permission for my child (of >15 years old) to be seen without the presence of an 

adult. 

_______  I give permission for my child (of >15 years old) to have minor procedures or 

immunizations without the presence of an adult. 

_______  I give permission for my child to be taken to medical appointments 

by:_____________________________________________________________________

________________________________________________________________________ 

Patient/Parent/Guardian Contact Numbers: Home____________  Work___________  Other__________ 

Signature of the Patient or their Parent/Legal Guardian ________________________________________ 

                  Form #116                                        

02/15/2012 

ARIZONA COMMUNITY PHYSICIANS REGISTRATION ADDENDUM

Patient Name:____________________________________________ Account Number:_________________________________________

Due to a governmental mandate that all healthcare is provided fairly, without regard to race or ethnicity, we have added new fields to our patient registration form. This information will be kept confidential.

Race (check one)

Black, African American (01)

Asian (02)

Caucasian (White) (03)

American Indian, Alaskan Native (08)

Native Hawaiian/Other Pacific Islander (09)

Unknown (98)

Declined (99)

Ethnicity (check one)

Hispanic

Non- Hispanic

Unknown

E-mail

______________________________

______________________________

Patient Signature

Preferred Language (check one)

English (EN)

Spanish (ES)

Arabic (AR)

Chinese (all types) (ZH)

French (FR)

German (DE)

Greek (EL)

Italian (IT)

Japanese (JA)

Korean (KO)

Navajo (NV)

Polish (PL)

Russian (RU)

Tagalog’ (TL)

Ukrainian (UK)

Vietnamese (VI)

Other________________ (Specify)

______________________________ _________________________

Parent/Guardian Signature Patient declined filing out the

form. Staff signature required

ARIZONA COMMUNITY PHYSICIANS, P.C. AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION

PATIENT INFORMATION Patient Name_________________________________________ Account #_____________________ Former Name (If any)________________________________________________________________ Daytime Telephone____________________________________ Birth Date_____________________ INFORMATION TO BE RELEASED FROM I hereby authorize (name of organization)_________________________________________________ To release the following medical information contained in patient’s medical record. INFORMATION TO BE RELEASED TO Name of Physician/Organization _____________________________________________________ Street Address ____________________________________________________________________ City/State/Zip_____________________________________________________________________ Phone # _________________________________________________________________________ PURPOSE FOR THE REQUEST (Please check a box) Moving Treatment or consultation Dissatisfaction Change of Insurance Plans At patients requestٱ Other (specify) _____________________________________________________________________ TYPE OF INFORMATION TO BE RELEASED (No information will be released unless a box is checked)

General Release DATES OF TREATMENT Medical Records/Excluding Protected Records (This will be limited to 1 year of information including Lab, x-ray reports From________ To_______

unless otherwise stated)

Other Records (specify) ________________________________ From________ To________ Information Protected by State/Federal Law All of my records including: From_______ To________

AIDS/HIV and Other Communicable Disease Information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment

THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE AFTER ONE YEAR (or 60 days for drug and alcohol abuse records) from the date of signing. The undersigned may revoke this authorization at any time by providing written notice of revocation. With respect to drug and alcohol abuse treatment, information or records regarding communicable disease-related information, the recipient of this information understands that it is prohibited from making any disclosure of this information unless further disclosure is expressly permitted by written consent of the undersigned or otherwise permitted by applicable law. Signature of Patient or Personal Representative Who May request Disclosure I understand that Arizona Community Physicians may not condition my treatment on whether I sign this authorization form unless specified above under Purpose for Request. I can inspect or receive a copy of the protected health information to be used or disclosed. I authorize Arizona Community Physicians to use and disclose the protected health information specified above _______________________________________ __________ __________________________________ Signature of Patient OR Legal Representative Date Please Print Name of signing party FORM # 100

Patient Requesting Medical Record Copies The charge for copying medical records from a paper chart will be $0.50 a page. For offices using our Electronic Health Record system, patients may request a copy of their chart on a “CD” for $10.00