JACK SCARIANO JR, M.D., PLLC
History Form
(Please complete this form in full prior to your visit)
DATE: ______DOB: ______
NAME: ______AGE: ____ SEX: M / F ___PRIMARY MD: ______
INSURANCE TYPE: ______
CHIEF COMPLAINT: ______
ALLERGIES TO MEDICATIONS: ______
HISTORY OF PRESENT ILLNESS:
What were you referred for? ______
How often does it occur? ______
When did this begin? ______
Was there a situation that surrounded the onset of the problem? ______
Describe the characteristics of your complaint. (feels like?)______
______
At this time how would you describe the severity of the pain / problem? Mild ______Moderate ______Severe ______
Are there any other symptoms that may be related to the present problem? ______
______
What makes the symptom better _____ or worse______? (Ex. Sitting, standing, lying down, etc)______
______
Have you seen another physician in the past for this problem?______
______
MEDICATIONS CURRENTLY TAKING:
(Please list all present medications and non prescription / over the counter medications taken on a daily basis or as needed. Please include vitamins and herbal products.)
______
______
______
______
MEDICATIONS TAKEN IN THE PAST:
______
______
______
______
NEUROLOGICAL SYSTEM:
Do you have or have you ever been told you have:
Yes No Yes No
Headache Confusion
Headaches wake you up at night Memory problems more than age related peers
Seizures Trouble walking
Lost consciousness Can you take care of yourself?
Weakness Do you fall?
Numbness or tingling Disorientation
Dizziness Difficulty with speech
Double vision Other neurological problems not mentioned
Comments: ______
______
Do you currently have or have you had problems with?
Constitutional Gastrointestinal
Yes No Yes No
Fever Nausea
Weight loss >5lbs Vomiting
Increased fatigue Blood in your vomit
History of falls Liver disease
Jaundice
Ear, Nose, Throat & Mouth Abdominal pain
Yes No Change in bowel habits
Wear hearing aid(s) Ulcers or gastritis
Hearing loss
Ear pain/infections Genitourinary
Ringing in ears Yes No
Nose bleeds Urinary tract infections
Nasal congestion/drainage Painful urination
Inability to smell Difficulty starting/stopping stream
Sinus problems Incontinence
Balance (vertigo, spinning, etc.) Kidney stones
Cardiovascular Musculoskeletal
Yes No Yes No
Chest pain or angina Broken bones
High blood pressure Arm or leg weakness
Irregular pulse Arm or leg pain
Heart murmur Joint pain or swelling
High cholesterol Arthritis
Cardiovascular (Cont)
Yes No
Swelling in hands or feet
Leg pain while walking Integumentary
Respiratory Yes No
Yes No Skin disease
Asthma Breast pain or tenderness
Emphysema Unusual moles
Shortness of breath
Pneumonia Psychiatric
Bloody sputum Yes No
Anxiety
Endocrine Depression
Yes No
Diabetes Hematologic/Lymphatic
Thyroid disease Yes No
Excessive thirst/urination Anemia
Hemophilia
Allergic/Immunologic Blood transfusion
Yes No Persistent swollen glands/lymph nodes
Food, Inhalant (nasal) allergies HIV/AIDS
Autoimmune disease (i.e. lupus)
Comments: ______
______
Have you been seen by a Neurologist before? Yes____No____ Procedures performed? ______
Name of MD: ______Dates: ______
PREVIOUS HOSPITALIZATIONS AND SURGICAL PROCEDURES:
Date Where Type of surgery and reason / Hospital admission and reason Physician
______
______
______
______
Do you have a family member affected with:
Yes No Yes No
Brain Tumor Muscle disease
Seizures or epilepsy Neuropathy
Dementia / Alzheimer’s Parkinson’s
Multiple sclerosis Hypertension
Migraine Thyroid disease
Diabetes Stroke
Other neurological disorder (please list)______
IMMEDIATE FAMILY:
Age Age at Death Medical Problems
Mother ______
Father ______
Sister(s) ______
______
Brother(s) ______
______
Children ______
______
SOCIAL HISTORY:
Occupation: ______Marital Status: ______Number of Children: ______
Hobbies: ______
Do you smoke cigarettes? ______If so, how many packs a day? ______
At what age did you start? ______If applicable, at what age did you stop? ______
Do you drink alcohol? ______If yes, how much daily? ______
At what age did you start? ______If applicable, at what age did you stop? ______
Do you use recreational drugs? ______Type? ______
Do you exercise regularly? ______How frequently? ______
Weight: ______Height: ______
Females Only: Are you, or could you be pregnant? ______
Age at first full term pregnancy? ______Age at first menstrual period? ______Age at last menstrual period? ______
Ever used Oral Contraceptives? ______Ever used Hormone Replacement Therapy? ______
OFFICE POLICY
Please read this information carefully as this should prevent many unnecessary calls to our office.
Dr. Scariano decides what prescriptions to give you. He wants you to take the medications as directed until your next visit. Dr. Scariano will not change your prescription to a different medication over the phone. When you are given prescriptions, you will be given enough to last until your next visit. Please do not call the office for these reasons. Drug-Seeking behavior will be reported to the appropriate authorities per State and Federal guidelines and is cause for immediate discharge from our practice.
An insurance company may require precertification of the tests the doctor may order. This can take up to 3 weeks. We will call you when the tests have been scheduled. We do not give out test results over the phone. It is best to have the doctor explain the test results to you and suggest a treatment plan if necessary. This will be done on your next visit.
If you have FMLA, disability or other forms to be filled out, please bring them with you during an office visit. For accuracy, the doctor or nurse need to fill these out during a visit, otherwise we cannot complete them for you. The doctor usually charges to fill out some forms.
Please make a list for our chart of all the medications you take and update it on each visit as necessary. The doctor needs to be aware of medications other doctors have prescribed and other conditions you are being treated for.
In preparation for your appointment with the doctor, a nurse will review your medical records and/or history given either by your referring physician or by you. If the nurse feels in-office testing is needed to save time and insurance costs, these may be done prior to your being seen by the physician.
We try to see patients in a timely manner but if you feel you are waiting too long, please let us reschedule you.
If you miss your appointment, without calling in a timely manner, three (3) times you will not be rescheduled again and you will be discharged by us.
If you are given a medication that requires a prior authorization (PA) from your insurance we will be notified of this by your pharmacy. Please do not call the office to see if a medication has been approved. Your pharmacy has that information and will notify you. From experience, we know that some requests will be denied. At that time, you will be responsible to appeal your insurance or purchase the medication.
During business hours, the nurse and doctor are unable to come to the phone. You will be required to leave a message on the nurse’s voicemail. If the voicemail is left after 2:00pm, your call may not be returned until the next business day. If there is an emergency, please do not call the office; go to the emergency department at your nearest hospital.
If you call the office for any of the above reasons, your call will not be returned.
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Patient Signature Date
PERMISSION TO DISCLOSE INFORMATION FORM
I,______do hereby give my consent for any and all staff employed by Jack Scariano Jr MD PLLC to discuss my medical records including by not limited to testing, treatments, routine checkups, and other healthcare needs, as well as financial information regarding my medical accounts, and release any information to the following members of my immediate family or others listed below (no more than 3 names may be listed). You do not have to include the doctor that referred you to our office.
No employee or physician will hold discussions with or give any information to ANYONE who is not listed below.
______
Name Relationship
______
Name Relationship
______
Name Relationship
I give my permission for employees of Dr. Scariano’s office to leave messages in my absence at my home or work:
CIRCLE ONE: YES / NO
I further agree that I will not hold liable the staff of Dr. Scariano who discloses my personal medical/financial information to the family members/others listed above.
______
Signature Date
______
Social Security Number Date of Birth
PATIENT RECORD OF NON-ROUTINE DISCLOSURES
The HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of home. This document will hold for as long as the person named below is a patient of Dr. Scariano’s. It is the responsibility of the patient to request changes after initial signing.
I WISH TO BE CONTACTED IN THE FOLLOWING MANNER (Check ALL that apply):
_____Home Telephone (list #)______
_____OK to leave detailed message
_____Leave callback # only
_____Work Telephone (list#)______
_____OK to leave detailed message
_____Leave callback # only
_____Written Communication
_____OK to mail to home address
_____OK to fax to #______
PRIOR TESTING INFORMATION
Have you had any of the following tests done in the past 2 years? If yes, please list where and when.
MRI SCAN______
CT SCAN______
______I have NOT had any testing prior to my appointment with Dr. Jack Scariano.
______
Patient Signature Date
GENERAL INFORMATION
Last Name:______
First Name:______Middle Name: ______
Social Security Number: ______
Mailing Address: ______County:______
City: ______State: ______Zip Code: ______
Home Phone or Cell Phone: ______Work Number: ______
Date of Birth: ______MALE FEMALE (circle one)
Employer: ______Marital Status: ______
If you are under your spouse’s insurance policy, we need the following information:
Spouse’s Name: ______Spouse’s Employer: ______
Spouse’s SSN: ______Spouse’s DOB: ______
If you are under 18 years old, we need the following information:
Parent/Guardian’s Name: ______Parent/Guardian’s Phone Number: ______
If you are under your parent/guardian’s insurance policy, we need the following information:
Parent/Guardian’s Name: ______Parent/Guardian’s Employer: ______
Parent/Guardian’s SSN: ______Parent/Guardian’s DOB: ______
EMERGENCY CONTACT INFORMATION
Contact Name: ______Contact Phone Number: ______
Contact Relationship: ______
Who Referred You To Dr. Scariano? ( List Name and Phone Number)
______
AUTHORIZATION TO BILL INSURANCE
I hereby authorize Jack Scariano Jr MD PLLC to release to my insurance company, companies or their intermediaries or carriers, any medical or other information needed for claims reimbursement. I hereby assign/transfer and set over to Jack Scariano Jr MD PLLC all my right, title and interest to my medical reimbursement benefits under my insurance policy.
I also give permission under HIPPA law for any insurance that may be associated with my visits to Dr. Scariano to release information to Dr. Scariano when/if requested.
I understand that I am responsible for any copay or coinsurance and any balance remaining after insurance pays their portion and/or any balance due on my account should my insurance not pay within 60 days for any reason. I do hereby state that I have given a true and accurate accounting to Dr. Scariano of my present insurance coverage, that all the information is correct, and that I will notify Dr. Scariano immediately of any changes.
I understand that if I do not present my correct insurance at every office visit, that I may be responsible for any balances on my account. I also understand that these balances must be paid in full or payment arrangements must be made in a timely fashion. Failure to pay your balance in full or payment arrangements that go without payment for 30 days will be turned over to collections.
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Signature of Patient/Insured/Authorized Person Date
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Physician signature/initials
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