Caren J. Bennett, M.D., P.A. 7261 SHERIDAN STREET, SUITE 100-C HOLLYWOOD, FL 33024

(954) 441-6226 / FAX: (954)443-3994

PERSONAL INFORMATION

Name Date of Birth

Address Apt # Age

City State Zip

Cell Phone Home Phone

E-mail Address Social Security #

PHARMACY INFORMATION

Pharmacy Name Pharmacy Phone #

Primary Care Dr. Referred By

EMERGENCY CONTACT

Emergency Contact Phone # Relationship

INSURANCE INFORMATION

PRIMARY INSURANCE

Name of Insurance

Insurance ID #

Insured’s Name

Insured’s Date of Birth

Insured’s SSN #

Relationship to Patient

SECONDARY INSURANCE

Name of Insurance

Insurance ID #

Insured’s Name

Insured’s Date of Birth

Insured’s SSN#

Relationship to Patient

MARTIAL STATUS

SEX

ETHNICITY

LANGUAGE

Single

Married

Divorced

Widow(er)

Male

Female

Hispanic / Latino

Non-Hispanic / Non-Latino

English

Spanish

Other:

RACE

American Indian

Asian

Black or African American

White / Caucasian

Hispanic

Other

Native Hawaiian/Pacific Islander

Unreported/Refused to Report

Signature Date

COMPREHENSIVE MEDICAL HISTORY

GENERAL INFORMATION

Name:

Date of Birth: Date of last colonoscopy:

CHIEF COMPLAINT / REASON FOR TODAY’S VISIT

PAST MEDICAL HISTORY

AIDS or HIV +

Blood/Plasma Transfusions

Cancer ________________

Kidney Disease

Heart Disease

High Blood Pressure

High Cholesterol

Anemia

Asthma / Emphysema

Thyroid Problems

Diabetes Mellitus

Bleeding Tendency

Rheumatic Fever

Stroke

Depression

Other

Other:

SOCIAL HISTORY

Occupation:

Have you ever smoked cigarettes? YES NO

If yes, do you still smoke? YES NO

Do you drink alcohol? YES NO

How often / How much?

FAMILY HISTORY

X TYPE RELATIONSHIP X TYPE RELATIONSHIP

Celiac disease Colon polyps

Liver disease IBD / Crohn’s / Colitis

HOSPITAL / SURGICAL HISTORY

# OPERATION / SURGERIES DATE

1

2

3

4

5

ALLERGIES

Allergic to Egg or Latex No known allergies

MEDICATIONS

PLEASE LIST ANY PRESCRIPTION MEDICATIONS, OVER THE COUNTER MEDICATION, VITAMINS, HERBS OR NUTRITIONAL SUPPLEMENT THAT YOU ARE NOW TAKING. PLEASE INCLUDE THE DOSAGE AND FREQUENCY THEY ARE TAKEN.

NAME DOSE FREQUENCY NAME DOSE FREQUENCY

Change in activity capacity Arthritis Diarrhea

Heavy menstrual cycle Gout Reflux

Change in sleep pattern Joint swelling Ulcers

Weight gain Morning stiffness Hepatitis

Weight Loss Muscle aches Abdominal pain

Gallstones

Vomiting

Heartburn

Anxiety Asthma Indigestion

Headaches Coughing up blood Anal fissures

Depression Emphysema/COPD Black tarry stools

Meningitis Pneumonia Vomiting blood

Seizure Shortness of breath Constipation

Stroke Tuberculosis Nausea

Memory loss Hiatal hernia

Fainting spell, Dizziness Intestinal obstruction

Blackouts or near blackout Liver disease

Angina Hemorrhoids

Ankle Swelling Red blood after bowel movements

Cardiac catherization

Glaucoma Chest pain

Cataracts Congenital heart defects

Decreased vision Heart attack Jaundice

Decreased hearing High/low blood pressure Psoriasis

Sinus infections Murmurs Rashers

Frequent nosebleeds Skin cancer

Trouble swallowing

Swollen glands

Blood in urine

Frequent bladder infections Anemia

Kidney disease Sickle cell

Diabetes Kidney stone Easy bruising

Thyroid disease Painful urination Easy bleeding

Heat or Cold intolerance Urinary incontinence Blood clots

Urinating frequently Bone marrow

Signature Date

Endocrine

Skin

General

Neurology and Psychiatric

Hematology

Ear, Eyes, Nose & Throat

Kidneys & Urinary Tract

PLEASE CHECK ALL CONDITIONS YOU CURRNELTY HAVE OR HAVE HAD:

Musculoskeletal

Respiratory

Cardiovascular

Gastrointestinal

Caren J. Bennett, M.D., P.A. 7261 SHERIDAN STREET, SUITE 100-C HOLLYWOOD, FL 33024

(954) 441-6226 / FAX: (954)443-3994

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy

Practices of Caren J. Bennett, M.D., P.A. Our Notice of Privacy Practices

provides information about how we may use and disclose your protected

health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. If we change our notice,

you may obtain a copy of the revised notice by contacting us at the above

address.

Do we have permission to

Leave a message on your answering machine at home? Yes No

Leave a message on your cell phone? Yes No

Discuss your medical condition or results with any

other member of your household? Yes No

If yes, whom: Relationship

I acknowledge receipt of the Notice of Privacy Practices of Dr. Caren J. Bennett, M.D., P.A.

Signature Date

Print Name

Caren J. Bennett, M.D., P.A. 7261 SHERIDAN STREET, SUITE 100-C HOLLYWOOD, FL 33024

(954) 441-6226 / FAX: (954)443-3994

INSURANCE CONSENT FORM

CHARGES FOR SERVICES RENDERED

All charges for office services are due at the time of my visit to Caren J. Bennett, M.D., P.A. (the Practice). If an

insurance claim is filed by the Practice, I request that payment of all benefits be made on my behalf to the Practice.

FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for all charges for medical services rendered on my behalf, including

those not paid or reimbursed by my insurance company. I am aware of the fact that my insurance carrier may deny

payment for the services rendered. Therefore, if payment is denied, I agree to be personally liable and fully responsible

for such payment.

SHARING/DISCLOSING HEALTH INFORMATION

I authorize the Practice to share, disclose, or otherwise release medical information about me to my insurance company

or any other authorized entity involved in my healthcare in accordance with the provisions of HIPAA (i.e., related to

treatment, payment, or healthcare operations). I further authorize the Practice to gain access to medical records with

information relevant to my treatment form any and all other healthcare providers, including but not limited to

hospitals, laboratories, physicians, and others.

TREATMENT

I further authorize and consent Caren J. Bennett, M.D., her assistants and other Practice professional staff providing

outpatient medical treatment, supplies, services, equipment and other items related to my healthcare to me as

determined to be necessary in their professional judgment. I have been informed of the nature and purpose of the

treatment, and potential common side effects thereof, as well as alternative treatment modalities, the approximate

estimated duration of my healthcare, and that I am able to withdraw my consent for treatment either orally or in

writing whether prior to or during the anticipated treatment period.

EMERGENCY MEDICAL CARE

In the event that a life-threatening emergency occurs while I am in attendance at the Practice in which emergency

medical care or treatment is required, I hereby authorize the Practice and its related providers to arrange for the

care and treatment necessary to address my emergency medical condition. I further authorize the treating facility or

medical personnel to provide emergency medical care and treatment and I agree to be responsible for all medical

and related costs associated with such emergency and follow-up medical treatment.

CANCELLATION

I agree that I will provide at least twenty-four (24) hours notice to the Practice when canceling an appointment and

understand that a failure to provide such notice may result in a prolonged waiting period and/or cancellation fee.

Signature Date