1
DELAWARE MEDICAL GROUP, PC
Name ______SSN: ______
Last First. MI
Address______
Street City State Zip Code
Date of Birth ___/___/___ Age ___ Sex ___ Marital Status ___ (Spouse’ name if married)______
Home Phone (_____)______Work Phone (_____)______Cell Phone (_____)______
Employer______Occupation______
Family Doctor______Phone(_____)______
Referring Doctor (if different)______Phone(_____)______
Emergency Contact (name and phone # other than above)______
Pharmacy ______
Name Address (street number and address needed in order to prescribe any medication)
The following information is requested as part of the government’s implementation of the use of an electronic medical record (please check)
What is your race? Asian Black Hispanic White Other
What is your primary language? English Sign Language Spanish Other
What is your ethnicity? Latino Not Latino
Party Responsible for Billing (if different from patient)
Name ______SSN:______
Last First MI
Address______
Street City State Zip Code
Date of Birth ___/___/___ Age ___ Sex ___ Marital Status ___ (Spouse’ name if married)______
Home Phone (_____)______Work Phone (_____)______Cell Phone (_____)______
Employer______
Insurance Information(You will responsible for obtaining a referral and copay at the time of service; please present your insurance card to the receptionist)
Name of Subscriber ______DOB:______
Primary Insurance Company______ID#______Group#______
Secondary Insurance Company______ID#______Group #______
If your primary insurance is Medicare, does your employer pay for your supplemental insurance? ______
I hereby authorize you to pay directly to Delaware Medical Group, PC benefits due me out of indemnity under the terms of my policy issued by my company. For Medicare beneficiaries; I authorize any holder of medical or other information about me to be released to the Social Security Administration, it’s intermediaries or carriers and any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used inplace of the original and request payment of medical insurance benefits either to myself or the party who accepts assignment below. For all others: I hereby authorize Delaware Medical Group to release any information acquired in the course of my examination or treatment. Payment is authorized upon receipt of this statement for services rendered to me. This policy was in full force and effect at the time that these services were rendered. Payment of the amount as herein directed, in whole or part shall be considered the same as if paid by your company directly to me.
Legal Signature______Date ______
HIPAA NOTICE OF PRIVACY PRACTICES:
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protect health information. If you have any objections to this form, please speak with our HIPAA Compliance Officer in person or by phone at our main office number.
______
PRINT NAME SIGNATUREDATE
AUTHORIZATION TO TAKE PHOTOGRAPHS FOR COSMETIC PROCEDURES:
I give my permission to the DMG Practioners to take photographs as indicated by them. I understand that these photos are clinical documents and may be used for scientific purpose as they see fit.
______
PRINT NAME SIGNATURE DATE
Health Information
1.Why are you seeing the doctor today?
1
DELAWARE MEDICAL GROUP, PC
- Check any medical conditions you have ever had.
High blood pressure Arthritis Back problems/Disc disease
High cholesterol Depression/Mental illness Stroke
Diabetes Asthma Kidney Disease
Heart Disease Emphysema Acid Reflux/GERD
Thyroid Disease Bronchitis Cancer, type: ______ Other, please list:
- List any surgeries you have had in the past. Please include dates.
- List any medications, vitamins and/or herbs you are currently taking, along with dosages.
- Is there a family history of (please check):
Cancer Stroke Depression/Mental Illness Thyroid Disease
Heart Disease Asthma Hearing Loss Diabetes
Other, please list:
- Have you smoked more than 100 cigarettes in your life yes no
- If yes, how often do you smoke?
every day
some days
I am a former smoker; When did you quit?______
- How much have you smoked?
Number of cigarettes per day ______
Number of years smoked ______
Name:______DOB:______
- Do you drink alcohol on a regular basis? yes no if yes, how much: ______
- Do you use any recreational drugs not prescribed by a medical doctor? yes no
- Check any allergies you have to medication, food, and/or dye.
No known allergies Erythromycin IV Contrast Dye
Amoxicillin/Penicillin Sulfa Latex/Rubber Products
Other Medications, please list:
Food/Environmental, please list:
- Do you have history of any the following? Please check the appropriate box.
Problem with vision / Difficulty swallowing / Palpitations, irregular heart beat
Date of last eye exam: / Heartburn / Anemia
Ear pain / Anxiety / Blood transfusion
Ear drainage / Depression, mental illness / Diabetes
Hearing loss / Seizures, blackouts, fainting / Thyroid disease
Nasal congestion / Fever, chills / Arthritis
Sinus problems / Cough / Bowel problems
Nosebleeds / Cancer of breast, lung, other organ / Bladder problems
- Height ______Weight ______
Name:______DOB:______