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					                                         JEFFREY A. PUNIM, M.D.
                          INTERNAL MEDICINE & ENDOCRINOLOGY
                 17822 BEACH BLVD, SUITE 201, HUNTINGTON BEACH. CA 92647
                                TELEPHONE (714) 842-9500
          INFORMATION REQUIRED FOR CASE HISTORY FILE         Date: _________________

First Name:_____________________ Middle Name: _______________ Last Name: ______________________
Address: ___________________________________________________________ City: _____________________
State: ______ Zip: __________ Rent □ Own □ Birthdate: _____/_____/_______ Age: _______ Male □ Female □
Home Phone: (             ) _________________ Cell Phone: (                   ) _________________ SSN: __________________
--------------------------------------------------------------------------------------------------------------------------------------------
Employment Status:             Full Time □          Part Time □            Retired □          Unemployed □              Student □
Employer: __________________________________________ Occupation: _______________________________
Address: ________________________________________ City: _______________ State: _____ Zip: _________
Work Phone: (              ) ____________________ Driver’s License #: ____________________________________
----------------------------------------------------------------------------------------------------------------------------- ---------------
Marital Status:         Single □         Married □            Separated □           Divorced □            Widowed □
Spouse’s First Name :___________________ Middle Name: _____________ Last Name: __________________
SSN: ________________________ Birthdate: _____/_____/_______ Driver’s License #: ____________________
Employer: __________________________________________ Occupation: _______________________________
Address: ________________________________________ City: _______________ State: _____ Zip: _________
Work Phone: (              ) ____________________
----------------------------------------------------------------------------------------------------------------------------- ---------------
Emergency Contact: ______________________ Relationship: _________ Phone #: (                                       ) _______________
Address: ________________________________________ City: _______________ State: _____ Zip: _________
Nearest Relative (not spouse): __________________________________ Phone #: (                                    ) __________________
Address: ________________________________________ City: _______________ State: _____ Zip: _________
----------------------------------------------------------------------------------------------------------------------------- ---------------
Primary Care Physician: ______________________________________ Phone #: (                                       ) __________________
Referred by: ________________________________________________ Phone #: (                                        ) __________________
-------------------------------------------------------------------------------------------------- ------------------------------------------
                                                  INSURANCE INFORMATION

Do you have group medical insurance?    Yes □   No □
Primary Insurance Co.: ________________________  Secondary Insurance Co: _______________________
Address: _____________________________________   Address: _____________________________________
_____________________________________________    _____________________________________________
Member #: ___________________________________    Member #: ___________________________________
Group #: _____________________________________ Group #: _____________________________________
Insured’s Name: _______________________________ Insured’s Name: ______________________________
    PLEASE GIVE YOUR MEDICARE OR OTHER INSURANCE CARD TO THE RECEPTIONIST.

                           RELEASE OF INFORMATION / ASSIGNMENT OF BENEFITS

I hereby authorize Jeffrey A. Punim, M.D. to disclose when requested by the above name insurance carrier(s) or its
representative any and all information with respect to any illness(es) or injury(ies), medical history, or treatment and
copies of all medical records. A photocopy of this authorization shall be considered as effective and valid as the original.

Patient Signature: __________________________________________________ Date: _____________________
(or Parent/Guardian Signature)

I hereby authorize payment directly to Jeffrey A. Punim, M.D. of the surgical and/or medical benefits, if any, otherwise
payable to me for professional services rendered to me. I understand that I am financially responsible for the charges not
covered by this authorization. I further agree in the event of non-payment to pay the cost of reasonable legal fees, should
this be required.

Patient Signature: __________________________________________________ Date: _____________________
(or Parent/Guardian Signature)
                            JEFFREY A. PUNIM, M.D.
                    INTERNAL MEDICINE AND ENDOCRINOLOGY
                          17822 BEACH BLVD., SUITE 201
                          HUNTINGTON BEACH, CA 92647
                                  (714)842-9500
                           HEALTH QUESTIONNAIRE

Patient Name: _____________________________                 Date: ___________________

Special problems or symptoms:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
How long have you had this problem? ________________________________________

Have you ever consulted a physician for this problem? …………………Yes ___ No ___

If yes: How did the doctor diagnose your problem?
______________________________________________________________________________
__________________________________________________________________

      How did the doctor treat your problem?
______________________________________________________________________________
__________________________________________________________________

Are you allergic to any medications, foods, or other substances? ………Yes ___ No ___

If yes, what? _____________________________________________________________
________________________________________________________________________

List all medications you are currently taking:

NAME OF MEDICATION                DOSAGE          DIRECTIONS           DATE STARTED
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________
______________________            ________        ____________         _______________

                If you need more space to write, please use the back of this form.

When was the last time you had a physical examination? _________________________

How much tobacco do you use? _____________________________________________

How much alcohol do you drink? ___________________________________________
                           HEALTH QUESTIONNAIRE…continued

List all illnesses (serious or chronic) and all hospitalizations starting with the most recent.

MO/YEAR          ILLNESS/HOPITALIZATION/OPERATION(S)                     COMPLICATIONS
_________        ________________________________________                ________________
_________        ________________________________________                ________________
_________        ________________________________________                ________________
_________        ________________________________________                ________________
_________        ________________________________________                ________________
_________        ________________________________________                ________________

Family History:

                    Age (if living)        Illnesses        If deceased,      Cause of Death
                                                            Age at death
    Mother:
 Grandmother
  (Maternal):
 Grandfather
  (Maternal):
     Father
 Grandmother
   (Paternal):
 Grandfather
   (Paternal):
    Brother:
    Brother:
     Sister:
     Sister:



   Children:




Is there a family history of diabetes, heart disease, high blood pressure, cancer, or thyroid
trouble? If so, please explain:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

Have you been diagnosed to have diabetes or thyroid disease? _____________________
________________________________________________________________________
                       HEALTH QUESTIONNAIRE…continued

General State of Health:
Recent weight loss or gain: _________________________________________________

Eyes, Ears, Nose & Throat:
Eye trouble: _____________________________________________________________

Digestive:
Abdominal pain or problems: _______________________________________________
Liver problems: __________________________________________________________
Blood or black in stools: ___________________________________________________
Appendicitis: ____________________________________________________________
Rectal problems: _________________________________________________________

Heart and Lungs:
Chest pain: ______________________________________________________________
Shortness of breath: _______________________________________________________
High blood pressure: ______________________________________________________
Lack of stamina: __________________________________________________________
Coughing: _______________________________________________________________
Asthma: ________________________________________________________________

Urinary:
Kidney stones, blood in urine: _______________________________________________
Trouble urinating: ________________________________________________________

Gynecology:
Do you have periods? ……………..Yes ___ No ___         Date of last period: __________
Age at first period: ______ Any problems with periods? _________________________
Any female disorders? _____________________________________________________

Bones and Joints:
Bone or joint problems: ____________________________________________________

Nervous System:
Seizures or Fainting: ______________________________________________________
Headaches or Dizziness: ___________________________________________________
Nervous Problems or Depression: ___________________________________________
                           Jeffrey A. Punim, M.D.
                         17822 Beach Blvd., Suite 201
                         Huntington Beach, CA 92647

Patient: ______________________

In connection with the medical services that I am receiving from Jeffrey A. Punim, M.D., and his
staff, I hereby authorize Jeffrey A. Punim, M.D., and his respective agents to disclose any and all
information concerning my medical condition and treatment (including, but not limited to, super-
confidential information concerning sexually transmitted diseases, mental health, chemical
dependence, or other such information), including copies of applicable hospital and medical
records to:

       A.      Any third party payor covering the medical services of the patient;
       B.      Other health care professionals and institutions involved in the delivery of health
               care to the patient;
       C.      The proponent of any legally sufficient subpoena, or in response to a court order;
       D.      Employees and agents of the practice, to the degree necessary to facilitate the
               provision of health care services and payment for such services
       E.      Pharmacies; and
       F.      As otherwise required by law

When providing information to me, information may be transmitted to me by any or all of the
following means (initial all that apply):

      ___   Telephone messages on an answering machine
      ___   Messages to the following family members or friends:
________________________________________________________________________

In each case, the practice shall take reasonable steps to ensure that only the minimum necessary
information is disclosed in accordance with the above. I further understand that I have been
given access to the physician’s privacy notice and that I have had the opportunity to place special
restrictions upon the consent hereby given:
Special Restrictions:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

This consent is valid from the date executed until revoked in writing by the patient.

Signed: ___________________________                  Date: _________________________

Witness: __________________________

				
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