Patient Forms

Patient Information Questionnaire PATIENT INFORMATION Last Name: First Name: Middle Initial: Street Address: Email: City: State: Zip: Social Security #: Home Phone: ( ) Cell Phone: ( ) Date of Birth: Marital Status: Single Married Divorced Widowed Separated Other Work Status: Employed Retired Disabled Self-Employed Unemployed Other: Employer Name: Work Phone: In Case of Emergency, Notify: Relationship to Patient: Emergency contact Phone: ( ) Cell Home Work Pharmacy: Pharmacy Phone #: ( ) INSURANCE INFORMATION Responsible Party (check one): Self Other: Primary Insurance: ID/Policy #: Subscriber name: Self Spouse Parent Subscriber Employer: Group #: Subscriber Social Security #: Date of Birth: Secondary Insurance: ID/Policy #: Subscriber name: Self Spouse Parent Subscriber Employer: Group #: Subscriber Social Security #: Date of Birth: Tertiary Insurance: ID/Policy #: Group #: ACCIDENT INFORMATION Is Your Visit Related To A Recent Accident? Yes No If YES, Date of Injury/Accident: Type of Accident: Job* Automobile Other Brief Description of Accident: Are you represented by an Attorney? Yes No Name: Phone #: ( ) If your visit is due to a Worker’s Compensation Claim, you must have a referral and your visit must be pre-approved. Failure to provide this information will result in your appointment being rescheduled. PHYSICIAN INFORMATION Referring Practice Name: Referring Physicians Name: Referring Practice Address: State: Zip: Phone:( ) Primary Care Practice Name: Physicians Name: Primary Care Phy. Address: State: Zip: Phone:( ) Date: Name: Height: Weight: Age: Male Female MEDICAL HISTORY How and When did your pain begin? Month: Year: Chief Complaint (Describe your problem and/or your most disabling/severe pain): PAST MEDICAL HISTORY List all major illnesses and conditions you have ever been diagnosed with (ex: High Blood Pressure, Heart Disease, Diabetes, etc.): Past Surgical History: Surgery Year Surgery Year Give the dates of the test you have had to diagnose your pain (Month/Year): X-rays CT Scan MRI Other DRUG ALLERGIES Do you have any drug allergies? No know drug allergies Allergic to shellfish or X-ray dye? Yes No (List reaction below) Yes (please list drug and reaction below) Allergic to Latex? Yes No (List reaction below) 1. Shellfish or Xray dye reaction: 2. Latex reaction: 3. MEDICATIONS List all medication you are currently taking (Also include non-prescription drugs with dosages): Medication Dose Medication Dose 1. 5. 2. 6. 3. 7. 4. 8. FALL RISK ASSESSMENT Do you feel unsteady on your feet? Yes No Do you have a history of falling in the last year? Yes No REVIEW OF SYSTEMS Have you had or are you having problems with any of the following? (Please check all that apply to you.) General: Fevers Chills Sweats Fatigue Weight Loss/Gain Sleep Disturbance Cardiovascular: Palpitations Chest pain Fainting Ankle Swelling Breathing Difficulty Musculoskeletal: Joint Pain/Swelling Muscle Pain/Weakness Trauma/Fractures Respiratory: Cough Wheezing Coughing Up Blood Shortness of Breath Asthma Neurologic: Numbness Paralysis Seizures Migranes/Headaches Memory Loss Gatrointestinal: Constipation Indigestion Nausea/Vomiting Change in Bowel Habits Abdominal Pain Bloody Stool Jaundice Hematologic/Lymphatic: Abnormal Brusing Bleeding Enlarged Lymph Nodes Genitourinary: Urinary Frequency Painful Urination Blood in Urine Bladder Control Pelvic Pain Reproductive: Abnormal Menstral Period Pain with Intercourse Sexual Dysfunction Sexual Transmitted Disease Ear/Nose/Throat: Hearing Loss Earache Ringing in Ears Nosebleeds Skin: Rash Itching/Dryness Ulcers/Sores Hives Skin Changes Eyes: Blurry Vision Blindness Eye Pain/Discharge Sensitivity to Light Name: Date: SOCIAL HISTORY Which of the following describes your marital status? Single Married Separated Divorced Widow(er) Other: Do you live alone? Yes No If No, with whom do you share a household? Do you exercise? Yes No If Yes, how often? Type: Do you use tobacco products? Yes No If Yes, packs per day? Number of years? If No, have you ever? When did you Quit? Do you use smokeless tobacco ? Yes No If Yes, packs per day? Number of years? If No, have you ever? When did you Quit? Do you drink alcohol? Yes No If Yes, how many drinks per week? Wine Beer Liquor Do you use recreational drugs? Yes No If Yes, use per week? Type: Do religious beliefs prevent you from receiving blood or blood products? Yes No FAMILY HISTORY Please check all of the following that apply to your family members. Please indicate if they are alive or deceased. Relationship Status Asthma Anesthesia Problems Ataxia Bleeding Disorder Blood Clots (DVT) Cancer COPD Dementia Diabetes Emphysema Heart Disease Hypertension Migraines Multiple Sclerosis Neurofibromatosis Neuropathy Osteoprosis Parkinsonism Seizures Stroke Tyroid Disease Ulcers Mother ____Alive ____Deceased Father ____Alive ____Deceased Sister ____Alive ____Deceased Brother ____Alive ____Deceased Patient Name_______________________ Date of Birth_______________________ Limited Release of Information to Family/Friends for Physician Clinics HIM# 1315s I give my permission to my physician practice that is part of the UNC Health Care System to share certain personal health information about me with the individuals listed below. These individuals will 1 only be given information about me that is related to their involvement in my care or payment for my care.0F I understand that I am not required to complete this form in order to obtain health care. Name: _____________________________ Phone Number: _____________________________________ Relationship: ________________________ Talk to this person about (check each box that applies): ☐ Any non-sensitive2 information regarding my health care or payment for my health care. OR ☐ Only these things: My appointments – scheduling & reminders My test results My after visit summary (AVS) My bills Other: Name: _____________________________ Phone Number: _____________________________________ Relationship: ________________________ Talk to this person about (check each box that applies): ☐ Any non-sensitive2 information regarding my health care or payment for my health care. OR ☐ Only these things: My appointments – scheduling & reminders My test results My after visit summary (AVS) My bills Other: If I change my mind about the people or the contact information I have listed in this form, I will complete a new form with such changes. _________________________________________________DATE: ________________ TIME:___________ PATIENT SIGNATURE (or Authorized Representative) PRINTED NAME & RELATIONSHIP (if not patient): ___________________________________________ 1 This form is not a substitute for a health care power of attorney or other formal designation of an individual authorized to make health care decisions for you if you are not able. If an individual listed above is your guardian or agent (under a power of attorney), or is otherwise authorized by law to act on your behalf, your health care provider may share as much of your personal health information with that person as the law permits. This form is not a substitute for a valid HIPAA compliant written authorization when it is required to release copies of medical and billing records or information. 2 Non-sensitive information excludes mental health, alcohol and substance abuse, HIV and other communicable diseases, and genetic testing. This form is not considered sufficient authorization to release sensitive information. Chart Location: Consents *HIM1315* HDF5338 06/09/17 Patient Label Here Acknowledgement of Receipt of Notice of Privacy Practices v06 HIM # 720s The Notice of Privacy Practices is a complete description of my rights as a patient of a University of North Carolina Health Care System (“UNC Health Care”) affiliate. By signing below, I am stating I have received the UNC Health Care Notice of Privacy Practices. PATIENT SIGNATURE: _____________________________________________ (or authorized representative) PRINTED NAME:___________________________ DATE:________ TIME:_______ RELATIONSHIP, if not patient: ________________________________________ *HIM720* HDF4538 07/01/15 Chart Location: Consents Patient Label Here GENERAL CONSENT FOR TREATMENT (PAGE 1 of 6) HIM #129s I understand that the University of North Carolina Health Care System (UNC Health Care) is an integrated health system made up of various entities, including (but not necessarily limited to) UNC Hospitals; Rex Hospital, Inc.; High Point Regional Health; Regional Physicians, LLC; Premier Surgery Center, LLC; High Point Surgery Center, LLC; Premier Imaging, LLC; Caldwell Memorial Hospital, Incorporated; Chatham Hospital, Inc.; Henderson County Hospital Corporation d/b/a Margaret R. Pardee Memorial Hospital; the University of North Carolina at Chapel Hill, School of Medicine; Johnston Health Services Corporation; Nash Hospitals, Inc.; Nash MSO, Inc.; NHCS Physicians, Inc.; UNC Physicians Network, LLC; and UNC Physicians Network Group Practices, LLC (each referred to in this form as a “UNC Health Care affiliate” or collectively as “UNC Health Care affiliates”). This consent will be effective for 1 year after the date I sign it at any UNC Health Care affiliate of which I am a patient; however, this consent will not expire for services, claims processing or collection activities for admissions or visits occurring while this consent was in effect. Consent for Treatment/Care I consent to treatment and care by UNC Health Care affiliates and by their physicians and health care providers, including those who are located at sites other than

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