Neel P. Shah, MD Lynn Montano, APN

Anthony J. Catanese, MD, FACS

Neel P. Shah, MD Lynn Montano, APN

315 East Main Street Somerville, NJ 08876 (908) 722 – 6900

Patient Information

Name: ______Birthdate: ______

Home Phone: ______Cell# ______SS #: ______

Home Address:______email (optional): ______

City______State______Zip______

Check One: __ Minor __ Single __ Married __ Divorced __ Widowed __ Separated

Patient’s (or Parent’s) Employer: ______Work Phone: ______

Spouse (or Parent’s) Name: ______Work Phone: ______

Family/Referring Physician: ______Physician Phone: ______

Person to Contact in Case of Emergency: ______

Responsible Party (If Different Than Above):

Name: ______Birthdate: ______

Relationship to Patient: ______SS #: ______

Address: ______

Home Phone: ______Work Phone: ______

Insurance Information:

Name of Insured: ______Date of Birth: ______

Relationship to Patient: ______SS #: ______

Name of Employer: ______Union or Local #: ______

Insurance Company: ______Group #: ______ID#: ______

Do You Have Any Additional Insurance? If Yes, Complete the Following:

Name of Insured: ______Date of Birth: ______

Relationship to Patient: ______SS #: ______

Name of Employer: ______Union or Local #: ______

Insurance Company: ______Group #: ______ID#: ______

Authorization and Release:

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child to third party payors, adjustors, attorneys and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor or doctor’s group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents, I authorize the doctor to initiate a complaint to the insurance commissioner for any reason, on my behalf. The physician and the staff may contact me by email.

______

Signature of patient (or parent, if minor) Date

Name: ______Date of Birth: ______Age: ______

Referring Doctor(s):

please list name, address and phone number

______

Reason for Visit:

What is bothering you that needs to be addressed by the physician? Please be specific.

______

Past Medical History/Review of Systems:

If you have known problems with these systems or think you might, please answer yes or no. If yes, please explain.

______ENT (Hearing/Vision): ______

______Respiratory (Lungs): ______

______Cardiac (Heart Attack/Angina/Valve Disease): ______

______GI (Stomach/Intestines/Liver): ______

______Oncology/Hematology (Cancer/Blood or Bleeding Disorder): ______

______Endocrinology (Diabetes/Thyroid Disease): ______

______Neurology (Stroke/Headaches/Seizures): ______

FEMALES: Number of Pregnancies/Deliveries: ______Last Menses: ______Menopause: _____

Past Surgical History: (starting with the most recent)

Procedure Date Hospital

______

Hospitalizations:

Reason for Hospitalization Date Hospital

______

Medications, including nonprescritions, i.e., aspirin, ibuprofen (Advil, Motrin)

Medications Dose Frequency Date Started

______

Pharmacy and Phone Number: ______

Allergies to Medications, for example, penicillin or IV contract. Please specify type of allergy or reaction:

______

Family History: Please specify if these disorders run in your family. If yes, to what degree relative is affected (father, sister, etc.):

____ Kidney Disease: ______

____ Prostate Cancer: ______

____ Other Cancer: ______

____ Heart Disease: ______

____ Diabetes: ______

____ Stroke: ______

____ Anemia: ______

____ Seizure Disorder: ______

Social History:

Marital Status: ______Occupation: ______Any toxin Exposure? _____

Height: ______Current weight : ______

Tobacco Use? ______How Long? ______How Much? ______When Quit? ______

Alcohol Use? ______What type? ______How Much? ______

Recreational Drug Use? ______

Reviewed by: ______Date: ______