Patient Information

Name
DOB
SS#
Mailing Address
Email
City
State
Zip
Telephone
Cell Phone
Marital Status
Gender:
Male    
Female

Responsible Party - If not patient

Name
DOB
SS#
Mailing Address
City
State
Zip
Telephone
Cell Phone
Marital Status
Gender:
Male    
Female
Relationship to Patient

Employment Information

Employer
Office Phone
Occupation
Cell Phone

Primary Insurance

Name
ID#
Group#

Secondary Insurance

Name
ID#
Group#

Emergency Notification/Next of Kin - Someone not in household

Name
Relationship to Patient
Telephone

Dr. John Hill and/or staff may discuss my medical condition with the following people

Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient

Release of Information / Assignment of Benefits

I authorize the release of any medical information necessary to process my insurance claim. I authorize and request payment of medical benefits directly to my physicians. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me; I understand and agree that regardless of my insurance status I am responsible for any balance of my account.

I Agree

Health History Questionnaire

All questions contained in this questionnaire are protected by privacy acts under HIPPA and will become part of your medical record. Fill in the blanks or check appropriate answers.

Today's Date

Personal Health History

Childhood Illnesses:

Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio

Please indicate current vaccinations and DATE received:

Tetanus or TET/DIP
Tetanus Date
Pneumonia
Pneumonia Date
Hepatitis (series of 3)
Hepatitis Date
Chickenpox/Shingles
Chickenpox Date
Influenza
Influenza Date
MMR (Measles, Mumps, Rubella)
MMR Date

List any medical problems that other doctors have diagnosed or check applicable items on list.

High Blood Pressure
Hypothyroidism
Diabetes II
COPD
Peripheral Vascular
Heart Disease
High Cholesterol
Atrial Fibrillation
Asthma
Arthritis

Surgeries/Procedures (please fill in any that apply)

Carotid Endartectomy (remove plaque from neck vessels)
Thyroidectomy: Partial    Complete
Cardiac Catheterization. Stent: Yes    No
Pacemaker    Automatic Implanted Defibrilator
Aortic Aneurysm Repair
Vascular Bypass (specify location):
Breast Surgery: Mastectomy    Lumpectomy    Biopsy (non-cancer)
Chest Surgery
Kidney Surgery
Hip Replacement Left    Right
Knee Replacement Left    Right
Amputations:
Endoscopy of Esophagus/stomach/duodenum (EGD)
Colonoscopy - Findings: Polyps    Diverticulosis    IBS    Chron's
Cholecystectomy (Galbladder Removed) Open   Laparoscopic
Gastric Bypass - Type:
Appendectomy
Hysterectomy Abdominal    Vaginal (THIS UTERUS only, see below)
Ovaries & Tubes Left    Right
Tubal Ligation (sterilization)
Bladder - Specify:
Prostate: TUNA    TURP    OTHER:
Cataracts: Left    Right
Plastic Surgery - Specify:
OTHER:
OTHER:
OTHER:
OTHER:

Testing in the last two years

CT (computed tomography): Head    Chest    Abdomen    Pelvis
MRI: Head    Neck    Abdomen:    OTHER:
DEXA Bone scan for bone mass
Nuclear Medicine Scan

Other hospitalizations in the last 2 years

Date
Reason
Hospital
Date
Reason
Hospital
Have you ever had a blood transfusion? Yes    No
If yes, what year?
Have you ever had radiation therapy? Yes    No
If yes, indicate reason.
Have you ever had a blood clot in your legs or lungs? Yes    No
If yes, what year?

Allergies or intolerance to Medications?

Please list the drug and make sure you are specific about your reaction. List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers, eyedrops and nasal sprays

Name of drug (BRAND and Generic)
Reaction You Had
Name of drug (BRAND and Generic)
Reaction You Had
Name of drug (BRAND and Generic)
Reaction You Had

Current Medications:

Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS IN THIS SECTION ARE OPTIONAL AND WILL BE CONFIDENTIAL IN COMPLIANCE WITH PRIVACY POLICIES

The amount of exercise you get on a weekly basis. Please check the appropriate answer.

Sedentary (no exercise)
Mild exercise (climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (work or recreation, less than 4x / week for 30 min)
Regular vigorous exercise (work or recreation, 4x / week or more for 30 min)

Are you happy with your weight?

Yes No
Are you dieting?    Yes No
If yes, are you on a physician prescribed diet?    Yes No
How many meals do you eat in the average day?
Meal amount

How many caffeinated drinks do you consume?

None Coffee Cola Tea Other
# Of cups per day?

Do you consume alcoholic beverages? Please answer questions to the best of your ability.

None Beer Wine Mixed Drinks Coolers Other
How many servings per week?
Are you concerned about your drinking? Yes No
Have you ever experienced blackouts? Yes No
Have you considered stopping? Yes No
Are you prone to binge drinking? Yes No
Do you drive after drinking? Yes No

Do you now or have you ever smoked or chewed tobacco?

I smoke cigarettes: packs per day for: years.
I quit in: , I smoked: packs per day for years.
Chew times per day
Smoke Pipe times per day
Are you interested in quitting? Yes No

Personal questions related to your sexual health

Are you sexually active? Yes No
Are you or your wife trying for a pregnancy? Yes No
If not, how are you preventing pregnancy?
Any discomfort with intercourse such as pain or dryness? Yes No
Any problems with frequency or loss of interest in intercourse? Yes No

Questions about your health and safety.

Do you live alone? Yes No
Do you have frequent falls? Yes No
Do you wear glasses, contacts, hearing aids, or dentures? Yes No

Questions about your wishes.

Do you have an Advance Directive or Living Will? If yes please furnish a copy for your record. Yes No
If you do not, would you like information on the preparation of these? If yes please ask our staff or check our website. Yes No
Have you designated a Healthcare Surrogate? If yes, please furnish a copy of your designation for your records. Yes No
Are you an organ donor? Yes No

Family Health History

(Please complete to the best of your ability)

Father
Age
Health Problems
Mother
Age
Health Problems
Sibling
M   
F
Age
Health Problems
Sibling
M   
F
Age
Health Problems
Sibling
M   
F
Age
Health Problems
Sibling
M   
F
Age
Health Problems
Children
M   
F
Age
Health Problems
Children
M   
F

Age
Health Problems
Children
M   
F
Age
Health Problems
Children
M   
F
Age
Health Problems
Grandmother (Maternal)
Age
Health Problems
Grandfather (Maternal)
Age
Health Problems
Grandmother (Paternal)
Age
Health Problems
Grandfather (Paternal)
Age
Health Problems

Women Only

How old were you when you started menstruating?
Date of last menstruation:
How many pregnancies?
How many live births?
Are you pregnant or breastfeeding?
Yes   
No
Have you had a urinary tract, bladder, or kidney infection within the last year?
Yes   
No
Do you have problems with control of urination?
Yes   
No
Have you had any blood in your urine? Yes   
No
Any hot flashes or sweating at night?
Yes   
No
Date of last pap and rectal exam? Pap:
Rectal:
Have you had any of the following infections? Abnormal pap HPV Herpes HIV Chlamydia Gonorrhea

Men Only

Do you usually get up urinate during the night?
Yes   
No
If yes, # of times:
Do you feel pain or burning with urination?
Yes   
No
Any blood in your urine?
Yes   
No
Do you feel burning discharge from penis?
Yes   
No
has the force of your urination decreased?
Yes   
No
Have you had a urinary tract, bladder, or kidney infection within the last year?
Yes   
No
Do you have hesitancy in starting urination?
Yes   
No
Have you had any of the following infections? HPV Herpes HIV Chlamydia Gonorrhea
Do you have problems emptying your bladder completely?
Yes   
No
Any difficulty with erection or ejaculation?
Yes   
No
Any testicle pain or swelling?
Yes   
No
Date of last prostate and rectal exam:

Additional Information

Family, Significant others, and friends. Under certain circumstances, we may disclose PHI (Protected Health Information) to family members, other relatives, or close personal friends or others that you identify to improve communication of relevant information (most commonly laboratory results, prescription issues and or changes, appointment scheduling. etc.) to their involvement in your care or payment related to your care; or to notify them of your location, general condition, or death.

In compliance with this office's HIPPA policy, I am authorizing West Volusia Family & Sports Medicine's staff to release PHI as necessary to support and assist in my care. Please list each individual authorized to receive information as stated above and provide us with the information requested.

Please indicate if you wish to have your personal health care information released to your spouse, children, or significant other below:

Person 1:
Name:
Relationship:
Mailing Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 2:
Name:
Relationship:
Mailing Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 3:
Name:
Relationship:
Mailing Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 4:
Name:
Relationship:
Mailing Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Dear Valued Patient,

We are pleased that you have chosen to partner with us in the care of your health; however, in order to insure that you receive the best care possible and are taken care of in the most efficient way, we ask that you review the following office policies.

Healthcare Compliance:

  • We ask that you make every effort to comply with the physician recommendatios regarding routine follow-ups, medications, specialist referrals, procedures, etc.

Pain Management:

  • Please note that a referral will be made to a pain management specialist for chronic pain management medications at the discretion of Dr. Hill.

Prescriptions

  • Prior to office visits please make not of any refills needed.

Lab/Imaging/Sleep Study Follow-Up Policy

  • If no follow up appointment is made and labs/images/sleep studies are:
    • Abnormal - you will be contacted to schedule and appointment
  • You will receive a copy of your lab report at your scheduled follow up appointment

Cancellation / No Show Policy

  • Time has been specifically reserved for your physician appointment, procedure, or treatment. Please call at least 24 hours ahead of time if you must cancel an appointment. There is a $20 charge if you fail to show for a scheduled appointment or cancel with less than 24 hours notice.

I hereby expressly acknowledge the receipt of West Volusia Family and Sports Medicine's Notice of Privacy Practices.

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