patient registration form - 2019 · herbs, supplements, home remedies, birth control pills,...
TRANSCRIPT
Patient Information Last Name: First Name: M.I.: Previous Name (if applicable) Mailing Address: Apt # City/State/Zip: Home Phone: Cell Phone: Work Phone: Email Address: **PHARMACY / LOCATION: Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages: If Voice, Please Select Preferred Number: (Please Select Only One Option) Voice Text Patient Portal Home Cell Work Marital Status: Date of Birth: Sex:
❑ Male ❑ Female Social Security #: Emergency Contact Name: Emergency Contact Phone #: Relationship to Patient:
Responsible Party- If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor Last Name: First Name: Date of Birth: Social Security #: Phone: Address of Person Responsible: City/State/Zip: Relationship to Patient: How did you hear about us? Friends Family Co-worker Insurance Website ER/Urgent Care Internet: ____________________ Specialist Newspaper
Magazine Other _____________________________________________________________ When you are unavailable to answer the phone, may we leave detailed voicemails about your medical treatments, care plan, test results, referrals, and prescriptions? Yes No If yes, on which phone numbers? Home Cell Work
Race (please select): White American Indian or Alaska Native Asian Hispanic Black or African American Native Hawaiian or Pacific Islander Decline Other _______________________________________________________
Ethnicity (please select one): Hispanic or Latino Not Hispanic or Latino Other ___________________________________
Preferred Language (please select one): English Chinese Indian (including Hindi & Tamil) Filipino/Tagalog Spanish Russian Other _________________________________
Primary Medical Insurance Secondary Medical Insurance Ins. Co. Name Ins. Co. Name Policy Holder Name: Policy Holder Name: Policy Holder's Date of Birth: Policy Holder's Date of Birth: Policy Holder's Social Security #: Policy Holder's Social Security #: Patient Relationship to Policy Holder: Patient Relationship to Policy Holder:
Our office uses our online Patient Portal extensively to communicate with our patients. Patients can view lab results, book appointments, request refills, update key information, pay balances, and many other functions via Patient Portal. Be sure you sign up for it.
Patient Registration Form
2545 E. Bidwell St, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628
(Phone) 916-983-8868 (Fax) 916-983-8891 www.HealthyLivingPC.com
Your prescriptions may be delayed if we do not have your pharmacy information on file.
*Pharmacy / Location
Please go to next page Page 1 of 3
Name Date of Birth
Comprehensive New Patient Health History Questionnaire
Main reason for today’s visit:
Please list all healthcare providers you see regularly:
PERSONAL MEDICAL HISTORY: Have you ever had any of the following conditions?
Condition Now Past Condition Now Past
Alcohol / Drug abuse Gynecological Conditions (Endometriosis)
Allergy (Hay Fever) ( ) Gynecological Conditions (Fibroids)
Anemia Gynecological Conditions (Other)
Anxiety Hepatitis – Type A | B | C
Arthritis (Rheumatoid) Herpes (cold sore or genital)
Arthritis (Osteoarthritis) High Blood Pressure
Asthma High Cholesterol
Bladder / Kidney Problems Inflammatory Bowel Disease
Blood Clot ( ) Irritable Bowel Syndrome
Cancer ( ) Kidney Disease / Failure
Cataracts Kidney Stones
Chronic Pain ( ) Liver Disease
Colon Polyp Migraine Headaches
Coronary Artery Disease Osteoporosis
Depression Prostate (enlargement)
Diabetes (adult onset) Seizure / Epilepsy
Diabetes (childhood onset) Sleep Apnea
Diverticulosis Stomach Ulcer
Emphysema (COPD) Stroke
Fractures (broken bones) Thyroid (Nodule)
Gallbladder Disease Thyroid High (Overactive) / Hyperthyroidism
Gastroesophageal Reflux (Heartburn/GERD) Thyroid Low (Underactive) / Hypothyroidism
Glaucoma Other ( )
Gout Other ( )
SURGICAL & PROCEDURE HISTORY – Please enter the year of any procedures or surgeries below.
Surgical Procedure Year Surgical Procedure Year
Abdominal surgery ( ) Hysterectomy (partial, ovaries left)
Appendectomy (appendix removal) Hysterectomy (total, including ovaries)
Back surgery Joint Arthroscopy ( )
Biopsy ( ) LEEP (Cervix surgery)
Breast Biopsy Neck Surgery
Breast surgery Ovary Removal
Cataract surgery Sinus Surgery
Coronary Bypass Tonsillectomy
Coronary Stent Tubal ligation
C-Section Urological Surgery
Gallbladder Removal Vascular Surgery ( )
Heart Surgery( ) Vasectomy
Hip Surgery ( ) Other ( )
Please go to next page Page 2 of 3
FAMILY HISTORY
Adopted? No Yes. If adopted, and you do not know your birth family’s history, skip this Family History section.
Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes.* If some siblings are alive and some are deceased use the space to the right to explain further.
Mo
ther
Fat
her
* S
iste
r(s)
* B
roth
er(s
)
Mo
m’s
Mo
m
Mo
m’s
Dad
M
om
’s
Sib
ling
s D
ad’s
Mo
m
Dad
’s
Dad
D
ad’s
Sib
ling
s
Alive Deceased
Age currently or at death
Diseases & Conditions Mo
ther
Fat
her
Sis
ter(
s)
Bro
ther
(s)
Mo
m’s
Mo
m
Mo
m’s
Dad
M
om
’s
Sib
ling
s D
ad’s
Mo
m
Dad
’s
Dad
D
ad’s
Sib
ling
s
Other blood relatives (list relationship to
you)
No significant history known
Hypertension – high blood pressure
Hyperlipidemia – high cholesterol
Heart Attack, Angina (Coronary Artery) Disease)
Diabetes Type I (childhood onset)
Diabetes Type II (adult onset)
Osteoporosis
Depression Alcoholism / Drug abuse
Alzheimers
Asthma
Autoimmune Disease
Bleeding or Clotting Disorder
Cancer ( ) Colon Polyp Emphysema (COPD) Genetic Disorder (explain)
Heart Disease (CHF)
Hepatitis B or C
Hypothyroidism / Thyroid Disease
Kidney Disease
Stroke
Sudden Cardiac Death
Other ( )
Other ( )
MEDICATIONS: Please list (or show us your own printed record) all prescription and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc).
Check box if you do not take any prescription or over the counter medications. Check box if you brought a list of your medications (give it to my assistant and don’t write in medications below).
ALLERGIES or intolerance to medications? No known drug allergies
(If yes, to what & what reaction?)
Medication Dose
(e.g. mg/pill) How often?
Medication
Dose (e.g. mg/pill)
How often?
Thank you for taking the time to complete this form Page 3 of 3
IMMUNIZATIONS: I have voluntarily declined all vaccines in the past.
Vaccine Date Vaccine Date Vaccine Date
Hepatitis A Pneumovax (Pneumonia) Whooping Cough (DTaP)
Hepatitis B Prevnar 13 (Pneumonia) Shingrix (shingles)
HPV Tetanus (Td)
Influenza (flu shot) Varicella (Chicken Pox)
HEALTH MAINTENANCE SCREENING TESTS:
Test Date Result Test Date Result
Screening Labs □ Normal □ Abnormal Sigmoidoscopy □ Normal □ Abnormal
Physical Exam □ Normal □ Abnormal Colonoscopy □ Normal □ Abnormal
Endoscopy □ Normal □ Abnormal Stress Test □ Normal □ Abnormal
Women Only
Mammogram □ Normal □ Abnormal Bone Density Test (DEXA) □ Normal □ Abnormal
Pap Smear □ Normal □ Abnormal
Alcohol/Tobacco/Drug Use History:
Alcohol Use
Alcohol Use: Yes Not Currently Never Defer How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 3 or 4 5 or 6 7 or 9 10 or more Patient Refused
How often do you have a drink containing alcohol?
Never Monthly or Less 2-4 times a month 2-3 times a week 4 or more times a week Patient Refused
How often do you have six or more drinks on one occasion?
Never Less than monthly Monthly Weekly Daily or almost daily Patient Refused
Drinks/week:
____ Glasses of wine ____ Cans of beer ____ Shots of liquor ____ Standard drinks or equivalent
Tobacco Use Drug Use
Smoke / smoked □ Cigarettes □ E-Cigarettes □ Pipe □ Cigar □ Chewing Tobacco □ Snuff Tobacco □ None
Have you ever used recreational drugs? No Yes
Currently Using:
Used in the past:
Number of uses per week:
Never Smoked
Current smoker: Packs/day: Year Started:
Are you ready to quit? No Yes
Former smoker: Year you quit:
Approximately how many packs/day did you smoke?
Year you start smoking?
SOCIAL HISTORY:
Marital status: single partner married divorced widowed Spouse/partner’s name:
Number of children: Number of grandchildren: Number of great grandchildren:
Education: high school or GED trade school college graduate school other
Occupation: Employer:
If you are not working, you are: retired unemployed on a leave of absence disabled homemaker other
WOMEN’S HEALTH HISTORY:
Total number of pregnancies: Number of births: Number of miscarriages: Number of abortions:
Healthy Living Primary Care 2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 • 11634 Fair Oaks Blvd, Fair Oaks, CA 95628
Phone: (916) 983-8868 Fax: (916) 983-8891
Office Policies
WELCOME TO OUR PRACTICE: We are glad you have selected our office for your healthcare needs. Our care
team includes physicians, mid-levels, and many other supporting staff. We work as a team to provide quality
care to people of all ages. We offer personalized care through the use of the latest in medical information and
diagnostic technology. Developing a strong and long-lasting relationship between the patient and physician is
important to us.
KNOW YOUR INSURANCE PLAN: Under the dynamic changes of the insurance world, it is critical for patients
to understand their own insurance benefits and restrictions. Until your deductible is met, office visits, blood
work and imaging tests are the patient’s responsibility. Preventive lab tests are only limited to cholesterol
panel, complete metabolic panel, complete blood count, thyroid test, and prostate enzyme. Any other tests
are subject to potential out-of-pocket payments, depending on your plan. Preventive visits only cover
screening for high blood pressure, cholesterol, breast exam, Pap smear, vaccinations and physical exam.
Discussion of any medical condition during your preventive visit is subject to an additional charge for a sick
visit.
APPOINTMENTS: One of the goals of this office is to respect our patients’ time by having you in the exam
room at the time of the scheduled appointment as opposed to being in the waiting room. In the event that
you are inadvertently delayed in your arrival for your appointment, every effort will be made to fit you into
the existing schedule. However, there may be times that we will request that you re-schedule your
appointment if we cannot accommodate you.
CANCELLATIONS: If you find that you need to cancel your appointment, please provide the office with 24-
hours’ notice to avoid a $50.00 No-Show/Same-Day cancellation fee via Patient Portal, phone call or voicemail.
We will be glad to reschedule you to a more convenient time.
CHRONIC DISEASE MANAGEMENT PROGRAM (if you qualify): If you have at least two chronic diseases, you
qualify for our Chronic Care Management Program at no charge to you. This program’s goal is to make sure
that your health is well managed. Our designated CCM specialist will review your chart monthly for such
things as preventative care, medication reconciliation, RX refills, and medical management by other
specialists. Patient understands that only the primary care physician can administer this program and that
patient can opt out of the program anytime.
I understand and agree to all the above policies.
Patient’s Name: ____________________________________ Parent’s/Conservator’s Name: _____________________________
Patient’s/Parent’s/Conservator’s Signature: _________________________________________________ Date:_____________
Healthy Living Primary Care
Office Procedures LABS:
• Lab orders are sent to Quest electronically for your convenience. You can go to any Quest without a printed order. If you would like to go to LabCorp, we will print you the lab order.
• If you are given a paper slip at check out, it is important to bring that lab slip with you to the lab.
• You can make appointments online at www.QuestDiagnostics.com to cut down wait time.
• If you have a PPO, most lab tests count toward your deductible. For most insurances, preventive lab tests are limited to cholesterol panel, comprehensive metabolic panel, complete blood count, thyroid test, and prostate enzyme. Please call your insurance if you have questions about cost and coverage.
IMAGING TESTS:
• Call Sutter Imaging to schedule the test and bring in the printed order.
• However, any patient with Covered California and Connected Care needs to go to Mercy Imaging
• If prior authorization is required by your insurance, we will obtain the authorization and you will be contacted through our Patient Portal once this is complete. Depending on the urgency of your exam, prior authorization can take up to 7-10 business days to process.
REFERRALS:
• Please allow up to 7-10 business days to process your referral unless it is medically urgent. You will be notified through our Patient Portal when your referral is done.
• Please make an appointment with the specialist within 30 days because many offices will disregard the referral after 30 days. There is a $25 fee for any repeat referrals.
• All pertinent medical information will be sent with the referral to the specialist. You also have access to your medical record through our Patient Portal if anything additional is needed by the specialist.
• We will do our best to refer you to a specialist within your insurance network. However, it is your responsibility to confirm that the specialist is in your network before receiving services with that office.
TEST RESULT:
• We will always notify you of all test results. If you do not hear from us after 2 weeks, contact us via Patient Portal.
• For routine or preventative lab/tests, our providers will send you the interpretation of the test results through our Patient Portal. Afterward, you will also be able to view your results on Patient Portal.
• If the test result is abnormal and requires an in-depth discussion, we will contact you via Patient Portal to schedule a follow-up appointment.
• For follow-up tests, our provider will discuss the test results with you in detail at your next follow-up appointment.
• If any test result is urgent, you will be contacted by phone.
KNOW YOUR INSURANCE PLAN:
• Under the dynamic changes of the insurance world, it is critical for patients to understand their own insurance benefits and restrictions. Until your deductible is met, office visits and tests are the patient’s responsibility.
URGENT CARE/AFTERHOUR CARE:
• We have multiple providers here daily to take care of your urgent medical needs. You should be able to get an appointment with someone on our care team on the same day if you call early in the day. If you need care after office hours, on-call doctors are available for consultation 24/7. Directions to local urgent care centers are outlined in our voicemail message. Keep in mind that for life threatening emergencies you should call 911.
RX REFILLS:
• Please check for any refills you might need prior to each visit. If you need a prescription refill between visits, please contact your pharmacy and they will send an electronic request to our office. You can also request for medication refill on Patient Portal. Please allow 24 to 48 hours for your prescription to be approved by the physician and processed by our office. However, we are not able to refill narcotic medication without a visit.
I understand and agree to all the above office procedures.
Patient’s Name: ___________________________ Parent’s/Conservator’s Name: _____________________________
Patient’s/Parent’s/Conservator’s Signature: ___________________________________________ Date:_____________
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Healthy Living Primary Care
2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628
Phone: (916) 983-8868 Fax: (916) 983-8891
Medication History Consent
By signing below I give permission for this medical office to access my pharmacy benefits data electronically through RxHub. This consent will enable this medical office to: • Determine the pharmacy benefits and drug co pays for a patient’s health plan.
• Check whether a prescribed medication is covered (in formulary) under a patient’s plan.
• Display therapeutic alternatives with preference rank (if available) within a drug class for medications. • Determine if a patient’s health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe
to these pharmacies.
• Download a historic list of all medications prescribed for a patient by any provider. In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub. _________________________________ Patient Name _________________________________ _________________ Patient Signature Date
Healthy Living Primary Care
2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628
Phone: (916) 983-8868 Fax: (916) 983-8891
Consent for Text Message Reminder
I hereby give my consent to Healthy Living Primary Care to use SMS Text Messaging at mobile
phone number _______________________ for appointment reminders ONLY. I
understand that I will be provided with the option to confirm or cancel my appointment via text
messaging. However, if I would like to reschedule I will need to contact Healthy Living Primary Care
at 916-983-8868. I also understand that my mobile service provider may charge a SMS text message
fee for any messages sent and/or received from my phone number.
Patient Name: Please print
Signature: Date:
In the event of a Parent/Guardian signing for a minor, please state your relationship:
All patients have the right to change their minds. If you wish to change your reminder option, please
notify reception. If you change your phone number please inform us so that we can update our
records.
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