PATIENT REGISTRATION

"Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying **

First Name: ___________ _ Last Name: __________ _ Middle Initial : __ _

Address: ____________ Apt #: ___ City: ______ _ State: ___ Zip: ___ _

Date of Birth: ------.1 __ -'/ __ _ Marital Status: Single / Married/ Separated / Divorced / Widowed

Who referred you? Doctor's Name: _____________ Phone #: ( __ ) ______ _

Social Security Number: ~ ___ -'/ __ _ Drivers license #: ________ _ State:

Employer/ School: __________ _ Occupation : ________ _ Sex: Male or Female

Home #: ( _ _ ) _______ Cell #: ( __ ) ______ Work #: ( __ ) _____ Ext.: ------------------------------------------------------------------------------------------------------------------------------------:..----------------------------------------------------

Emergency Contact Name: ______________ _ Relationship: ______ _

Home #: ( __ ) ______ Cell #: ( __ ) ______ Work #: ( __ ) ______ Ext.: __ _

Primary Insurance Name: ________________ PPO/HMO/POS/INDEMINTY /other: ____ _

Insured Name: ____________ _ Date of birth of policy holder: ----.-! ---.-1.;..' __ _

Insured Social Security #: ___ ..J1 ___ -'1 ___ _ Relationship: SELF I HUSBAND / OTHER: _____ _

ID/Policy /Cert. #: ________________ _ Group/Account#: ____________ _

Secondary Insurance Name (if any): ______________ PPO/HMO/POS/INDEMINTY /other: _____ _

Insured Name: _____________ _ Date of birth of policy holder: ~ ----.-! ___ _

Insured Social Security #: ___ ...JI ____ --'/ ____ _ Relationship: SELF / HUSBAND / OTHER: _____ __

ID/Policy/Cert. #: _______________ _ Group/Account #: ____________ _

RESPONSIBLE PARTY (IF OTHER THAN PATIENT) :

Name: ________________ _ Date of birth: ~ ----.-! __ Relationship : _____ __

Address: ________________ _ Apt #: ___ City: ______ __ State: __ _ Zip: ___ _

Social Security #: __ ---'1---.-1 __ _ Employer Name: ___________ _ Occupation: _______ _

Home #: ( __ ) ________ Cell #: ( __ ) _______ Work # : ( __ ) _______ Ext.:

MEDICAL CARE: I authorize Dr. Padma Horvit, M.D., P.A. or her designee to provide myself or my child with reasonable and proper medical care

according to today's standards.

MEDICAL INFORMATION : I authorize Dr. Padma Horvit, M .D., P.A. staff and bill ing representat ive to release my information necessary to my or

my child's insurance company(s), third party payor so that they may obtain payment for medical services rendered.

INSURANCE AUTHORIZATION : I hereby authorize Dr. Padma Horvit, M.D., P.A. staff and billing representative to furnish information to my or

my child's insurance company (s) concerning treatment rendered by Dr. Padma Horvit M .D., P.A. or her designee.

ASSIGNMENT OF BENEFITS: I authorize the insurance company(s) or any third party payor to pay benefits directly to Dr. Padma Horvit, M .D.,

PA, should they accept assignment for such treatment .

I ALSO AGREE THAT I AM FINANCIALY RESPONSIBLE FOR ALL CHARGES UNPAID BY MY INSURANCE COMPANY (5).

Signature of Patient or Guarantor: ____________ _ Today's date: ----.-! ---.-1 ___ _

Padma K. Horvit, M.D., P.A. Endocrinology

PATIENT QUESTIONAIRRE

Pharmacy name and number:

Do we have your permission to call you at work?

Yes No --

Do you authorize Dr. Horvit or her staff to leave medically related information on your home or work answering machine?

Yes No --

Patient's signature: _______________________ _

Date: -----------

PADMA K. HORVIT, M.D., P.A. ENDOCRINOLOGY

HEALTH HISTORY

Name: ________________________________ _ DOB: / / Sex: M F

Ref~edBy: ____________________________ _

Check all items that apply to you and fill in blanks as needed

Past Medical History:

_ Allergies (other than drugs ), __________ __

_ Anemia or blood problems

Arthritis

Asthma

_ Cancer/Tumor, explain: ______________ _

Colon disease

_ COPD, emphysema, lung disease

_ Diabetes, type __ , how long ___ _

_ Drug or alcohol abuse

_ Epilepsy

Glaucoma

_ Headaches, type __________________ ~

Past Surgical & Hospitalization History:

_ Angioplasty or _ Heart Bypass

_ Appendectomy

_ Back, procedure: __________________ _

_ Breast, R or L, procedure: ______ _

_ Cervical freezing or LEEP

Fracture, ________________________ _

Gallbladder

_ Hernia, R or L, type: ________ _

_ Hearing loss

Heart disease or heart attack

_ Hepatitis ABC or jaundice

_ Hypertension (high blood pressure)

_ Hypothyroid or hyperthyroid

_ Kidney disease or stone

_ Mental illness or depression

_ Pap smear, abnormal

_ Peptic ulcer disease

Stroke

Tuberculosis (TB)

Other: --------------------

_ Hysterectomy (uterus) Ovaries removed

_ Knee, R or L, procedure: ___ _

_ Psychiatric treatment, inpatient or outpatient

_ Tonsillectomy

_ Tubal ligation (Tubes tied)

_ Vasectomy

Other: _____________ _

Other: ----------

",--- -- ------- - --------------------- ------------

HEALTH HISTORY (cont'd)

Females Only: Age at first period: ----yrs. old Birth control method: ------

Number of: Pregnancies __ Live births __ Miscarriages __ Abortions

Date of last: Period --- Pap smear __ _

Males Only: Date of last: Physical exam __ _

Drug Allergies: _No Known Drug Allergies

Name of Drug

Mammogram ___ _

Prostate exam --- PSA __

Reaction

Current Medications: (prescription, over-the-counter, herbs, vitamins)

Medication StrengthIDose Frequency Medication StrengthIDose Frequency

Social History:

Marital Status: Married Divorced _ Single _Separated Widowed

Occupation: ___________ _ Highest level of education: _____ _

Tobacco: _Cigarettes Smokeless How muchlday: __ _ how long _ quit when __

Alcohol: Number of drinks per day or week _-----------

Caffeine: Number of cups of coffee __ /day, glasses of tea __ ---'/day, sodas __ /day

Do you exercise regularly? _______________________ ~

Family History:

Father Mother Father's father Father's mother Mother's father Mother's mother Brothers

Sisters

Children

Age Living Deceased

Health status or illness Cause of death & illnesses

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HEALTH HISTORY (cont'd) LIST OF SYMPTOMS

PLEASE CHECK ALL THOSE THAT APPLY

Excessive weight gain ____ lb. in _____ months

Excessive weight loss lb. in months

Excessive sweating, hair change or hot/cold insensitivity

Prolonged sore throat, hoarseness, or difficulty swallowing

Shortness of breath

Chronic cough

Chest pain or irregular heart beat

Abdominal pain, nausea, change in bowel habits or control

Change in urination frequency, pain upon urinating, incontinence

Change in menstrual cycle (Women) or impotence (Men)

Change in hearing

Change in sense of smell or taste

Blurred vision

Double vision

Excessive tearing or itching of eyes

Generalized weakness or fatigue (all muscles)

Specific limb or muscle weakness - specify:

Numbness - specify where:

Muscle pain or tenderness - specifY where:

Swelling of the ankles

Skin changes - specify:

Bruise easily

Memory loss

Nervousness

Change in appetite

Difficulty concentrating

Depression

Sleeping too much - average sleep per night: hours

Inability to sleep (Insomnia) - average sleep per night: hours

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LIST OF SYMPTOMS (cont'd)

Blackouts (fainting spells)

Lightheaded - the feeling of almost passing out

Vertigo - the feeling of the room or yourself spinning

Headaches

None of the above

Other - specifY:

Patient's signature: ___________________ Date: ____ _

Physician'S signature: __________________ Date: ____ _

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