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North Carolina Surgery NORTH CAROLINA SURGERY PATIENT IDENTIFICATION Patient’s Legal Name _________________________________________________________________________________ (LAST) (FIRST) (MIDDLE) Rex Healthcare will compare your Legal Name to your name as it appears on your insurance card. Gender ____ Last 4 numbers Social Security# (some insurances require full SS) ___________________ Birth Date _____________________ PATIENT INFORMATION: Race__________Hispanic_____Non-Hispanic________Language_________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ___________________________________ State ________________________ Zip Code _____________________ Home Phone # ____________________Mobile Phone #_______________________Email Address_______________ Referring Physician __________________________________________________________________________________ Primary Care Physician_______________________________________________________________________________ Other Physicians to Whom You Want Communication Sent _________ ________________________________________ PATIENT EMPLOYMENT INFORMATION Status: Full-time ___ Part-time ____ Retired ____ Retirement Date _________ Full Time Student? Y/N Other Employer’s Name ___________________________________________ Phone # _______________________________ GUARANTOR INFORMATION (Person Financially Responsible if different than patient) Name of Guarantor _______________________________________ Relationship to Patient _______________________ Last 4 Digits of Social Security # _____________ Gender _________ Birth Date ______________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ______________________________________ State _______________________ Zip Code __________________ Home Phone # _____________________________ Employer’s Name ________________________________________ EMERGENCY CONTACT INFORMATION Name of Emergency Contact _______________________________________ Relation to Patient ___________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ______________________________________ State __________________________ Zip Code _______________ Home Phone # _____________________Work Phone # ______________________Cell Phone # ____________________ PRIMARY INSURANCE Name of Insurance Company __________________________________________________________________________ Policyholder’s Name (if other than patient)_____________________________________ Relationship____________ Birth Date ________________ Gender ________ SECONDARY INSURANCE Name of Insurance Company __________________________________________________________________________ Policyholder’s Name (if other than patient)_____________________________________ Relationship____________ Birth Date ________________ Gender ________ ACCIDENT INFORMATION (Complete this section ONLY if your condition is accident related) Type of Accident (Auto, Work, Other) ________________________ Description______________ ___________________ Accident Date and Time ______________________Place of Accident (City,County,State) __________________________ Patient/Authorized Representative Signature __________________________________________Date_______________ NORTH CAROLINA SURGERY NAME ________________________________ DOB ________________ Today’s Date ______________ Reason for Visit ________________________________________________ ALLERGIES : ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ________________________________ ___________ ___________________________________________ MEDICATIONS : Please list all prescriptions and over the counter medications, herbs and vitamins Name _______Dose_____ Name___________________________Dose________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ ________________________________________ ______________________________________________ PHARMACY: Name: ______________________________________ Address: __________________________________ MEDICAL HISTORY: Breast Cancer--------- Colon polyps-------- Pancreatitis-------------- Gallstones ------------- Diverticulitis--------- Rectal bleeding--------- Colon cancer ----------- Fibrocystic breast--- Thyroid nodule--------- Abnormal EKG------- Heart disease------- Heart attack------------- Alcoholism ------------ Diabetes-------------- Seizures ----------------- Anemia---------------- Hepatitis------------- Stroke-------------------- Asthma ----------------- HIV/AIDS----------- CHF-------------------- High blood pressure Cirrhosis --------------- Kidney disease----- Clotting disorder------ COPD ------------------ Name: ______________________________ DOB: ___________________ SURGICAL HISTORY: Appendectomy----------------- C-section------------------ Prostate surgery------ Brain surgery------------------- Eye surgery--------------- Small intest. Surgery Breast surgery------------------ Fracture repair------------ Spine surgery-------- Open heart surgery------------- Hernia surgery------------ Tubal ligation-------- Gallbladder surgery------------ Hysterectomy------------- Valve replacement--- Colon surgery------------------- Joint replacement--------- Vasectomy------------ Cosmetic Surgery-------------- Stent Placement---------- FAMILY HISTORY: birth breast clotting Heart kidney Relationship alive/deceased defects cancer cancer disorder COPD disease Hypertension disease Mother Father Sister Brother Daughter Son SOCIAL HISTORY DOMESTIC ABUSE Tobacco Use No ___ Yes ___ former ____ Is abuse, violence, or sexual assault a problem for Alcohol Use No ___ Yes ___ smoker you in any way? No ____ Yes ____ Drug Use No ___ Yes ___ Does your partner/caregiver threaten you in anyway? No ____ Yes ___ INSTRUCTIONS: PLEASE CIRCLE "y" FOR ANY CURRENT SYMPTOMS CONSTITUTIONAL RESPIRATORY ENDOCRINE NEUROLOGICAL Y N Appetite change Y N Chest tightness Y N Cold intolerance Y N Dizziness Y N Chills Y N Choking Y N Heat intolerance Y N Headaches Y N Sweating Y N cough Y N Excessive thirst Y N Light-headedness Shortness of Y N Fatigue Y N breath GU Y N Numbness Y N Fever Y N Wheezing Y N Painful urination Y N Seizures Y N Weight change CARDIOVASC. Y N Flank pain Y N Fainting MUSCULOSKEL. Y N Leg swelling Y N frequency Y N Tremors Y N Back pain Y N Palpitations Y N Blood in urine Y N Weakness penile/vaginal Y N Gait problems GI Y N discharge HEMATOLOGICAL Y N joint swelling Y N Distention Y N scrotal/Pelvic pain Y N Adenopathy Y N neck pain Y N Abdominal pain Y N Urinary urgency Y N Bruise/bleed easy Y N Anal bleeding Y N Vaginal bleeding SKIN Y N Blood in stool Y N Vaginal discharge Y N Color changes Y N Constipation Y N Rash Y N Diarrhea Y N Wound Y N Nausea Y N Rectal pain Y N Vomiting 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)
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