Financial Information (Provide A Copy of Insurance Card(s)

 

 

 

 

 

 


                                                                                                                                                                                        

 

 

 

 

 


                                                                       

 

   

     

DEDUCTIBLES, CO-INSURANCES, AND/OR COPAYS WILL BE COLLECTED PRIOR TO ANY SURGERY OR AT THE TIME SERVICES ARE RENDERED IN OFFICE.

                                                                                     MEDICAL HISTORY                   

 

PATIENT NAME:_____________________________________________________________ Date of Birth__________________________

 

List any MEDICATION ALLERGIES:__________________________________________________________________________________

 

Are you Allergic to Latex?________________________________  If so, have you been tested for this?_____________________________

 

Are you Allergic to surgical tapes:_________________________

 

If we are seeing you for any type of injury , please give the DATE OF INJURY:_______________________________________________

 

How did the injury occur?_____________________________________________________________________________________________

 

Was your injury due to an MVA? _______________________  Which state did the MVA occur?       Arkansas             Oklahoma

 

Do you Smoke? _________________________________How much do you smoke?___________________________

 

Do you consume alcohol?___________________________ How much/often?_______________________________

 

Are you at risk for HIV (AIDS) ?_____________________  Have you ever been tested for this?______________ Results:________________

 

Surgical History

 

List all surgical procedures you have had:_________________________________________________________________________________

 

_____________________________________________________________________________________________________________________

 

_____________________________________________________________________________________________________________________

 

Have you ever had any complications from surgery?___________________ If so, please explain:____________________________________

 

 

Patient Name:__________________________________________________ Date of Birth___________________________________________

 

Have you ever had any complications from anesthesia:_______________ If so, please explain:_____________________________________

 

______________________________________________________________________________________________________________________

 

List all medications you currently take and the strength:_____________________________________________________________________

 

______________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________

 

How tall are you ?___________________________  What do you weigh?_______________________ Bra size (women only)______________

 

Personal History (this applies to patient only)

 

Have you ever had the following:

 

Heart Disease                  Yes   No                                    Psychiatric Illness                        Yes   No           

Respiratory Disease          Yes   No                                    Bleeding Disorder                        Yes   No           

Seizure Disorders             Yes   No                                    Ulcers                                        Yes   No           

Thyroid Problems            Yes   No                                    Cancer ______________               Yes   No           

High Blood Pressure        Yes   No                                    Other____________­­­­­­­­­­­______________

Stroke                           Yes   No

Diabetes             Yes   No

Hepatitis                        Yes   No

Depression                     Yes   No           

 

Family History (this applies to relatives)

 

Has anyone in your family ever had the following:

 

Heart Disease                  Yes   No                                    Psychiatric Illness                        Yes   No           

Respiratory Disease          Yes   No                                    Bleeding Disorder                        Yes   No           

Seizure Disorders             Yes   No                                    Ulcers                                        Yes   No           

Thyroid Problems            Yes   No                                    Cancer ______________               Yes   No           

High Blood Pressure        Yes   No                                    Other____________­­­­­­­­­­­______________

Stroke                           Yes   No

Diabetes             Yes   No

Hepatitis                        Yes   No

Depression                     Yes   No           

 

I certify that the above information is true and correct (Please sign below)

 

_____________________________________________________________________________ Date________________________________

Patient/Legal guardian

 

Is there any other medical information we need to know about that is not listed above?_______________________________________

 

__________________________________________________________________________________________________________________

 

Pharmacy Name:__________________________________________________________ Phone:___________________________________

 

 

                                   

                                                                                                                                                                                                                        Revised 12-07