Patient History

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					                                                                Patient History

Referring Physician: __________________________________________________________(MD, NP, PA) Office # (        ) __________________________________
                               (First & Last Name)                         (Circle type of provider)

Referring Physician Address: __________________________________________________________________ Fax # (       ) ___________________________________
                                         (Street)         (City, State, Zip)

Primary Care Physician:___________________________________________________________(MD, NP, PA) Office # (         )_______________________________
                              (First & Last Name)                              (Circle type of provider)

Referring Physician Address: _________________________________________________________________ Fax # (        ) ___________________________________
                                         (Street)         (City, State, Zip)

Other Treating Physicians: __________________________________________________________________ Office # (       ) __________________________________

If a physician did not refer you to our practice, how did you hear about us?__________________________________________________________________________
**************************************************************************************************************************************

Patient Name: _____________________________________________________________________________ Social Security # _______________________________
                    (First)                (Middle)                    (Last)

Sex M F               Date of birth ____/____/____         Age: ______          Marital status: Single  Married Divorced      Widowed

Home address: _______________________________________________________________________City:________________State:_______Zip:_______________

Home Phone:(   )___________________________________ Work # (       )_______________________________ Cell # (     )_______________________________

Employed by: ______________________________________________________ Address ____________________________________________________________
                                                                                        (street)                        (city/state/zip)
Emergency contact: __________________________________________ Phone: ( )_____________________________ Relation: ____________________________

Contact not living with you ___________________________________________Phone(     )__________________________Relation: __________________________

CONSENT AND CONDITIONS OF SERVICES
As either the patient or the legally authorized representative of the patient, the following consents, understandings, and agreements are
made on my own behalf or on behalf of the patient in partial consideration of the health care services to be provided to the patient by
Robert G Peterson, MD: On behalf of the patient, consent is hereby given to Robert G Peterson, MD to provide health care services to
the patient and to administer physician orders for the benefit of the patient for this visit and any subsequent visits, and it is understood
that this consent may be revoked in writing at any time. It is understood that there is a risk of substantial and serious harm involved in
such health care services, and such risk is accepted in the hope of obtaining beneficial results from such services. No promises of any
particular outcome or successful result have been made, it being understood and accepted that there is some uncertainty involved in
the outcome of health care services for which this consent is given. It is understood that physicians are separately responsible to
explain what they do. The law requires health care providers to make and keep records of your medical treatment. Access to medical
records is limited to persons who are providing, coordinating, evaluating, or improving health care, subject to applicable law. By
receiving services you agree to the release of medical record information for the uses specified above. You also agree to release
claims related information to insurance companies or other third party payor. Patient and the undersigned, if other than the patient,
remains responsible for all co-payments, deductibles, co-insurance, and/or non-covered services regardless of amount paid by
insurance or third party payor. It is understood and agreed that charges not paid in full within 60 days of billing will be subject to
interest at the rate of 18% annually. Accounts not paid in full in a timely fashion may be placed with a collection agency or attorney
for purposes of collection. It is further understood and agreed by the patient and the undersigned, if other than the patient, each jointly
and severally agree to pay costs and reasonable attorney’s fees in connection with the collection process up to 50% of amount owing.
A service charge may be collected in connection with any check or other instrument tendered by the patient or the undersigned but
returned unpaid to Robert G Peterson, MD. I have read and understand the document and I intend it to be legally binding subject to
applicable law.

I represent and warrant that all of the information provided to Robert G Peterson, MD in this information form is true, complete and
accurate. I understand and expect that Robert G Peterson, MD will rely upon this information in providing services to me.

____________________________________________________________________________________________________________
Signature                                            Date                      Relationship to Patient
Arbitration: Accepted / Declined (Please circle one)      Date: _____________________

Scheduling Information:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

                                                                                                    Chart # _____________________________
                                                            Patient History

What Complaints or symptoms lead you to seek medical help? _________________________________________________________

Where was your MRI done? ____________________________________________________________________________________

Past Surgeries & Hospitalizations (Include reason for hospitalization or surgery procedure performed)

       Procedure or Hospitalization                                Date                               Has the problem improved?




Height: ________________ Weight: _______________

Do you have any allergies to medications? Yes        No

If yes, Please list the medications and describe the reactions:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Past medical history and family history: Please check any of the following medical problems.

Yourself                                                               Family Members (ie. Father, Mother, Uncle, Aunt,Grandparents)
     Heart Trouble
         (Abnormal rhythm, Heart attack, Angina, Murmur)                    Heart Trouble ________________________________
     Pacemaker or Defibrillator
     High Blood Pressure                                                   Heart Attack or Angina _________________________
     Diabetes (Type I or II) Onset: _______________
     Lung Problems (Asthma, COPD, Other – TB, etc)                         High Blood Pressure ___________________________
     Sleep Apnea
     Kidney Disease                                                        Diabetes _____________________________________
     Cancer (Type __________________________)
     Convulsions (Epilepsy)                                                Lung Problems _______________________________
     Psychiatric History
     Hearing Loss                                                          Kidney Disease _______________________________
     Thyroid Trouble
     Weakness or Other Neurologic Deficits                                 Cancer (Type ________________________________)
     Adverse Reaction to Anesthesia
     Hepatitis                                                             Psychiatric History ____________________________
     AIDS or HIV exposure
     Drug or Alcohol Abuse                                                 Drug or Alcohol Abuse _________________________
     Chronic Pain
     Congenital Abnormality                                                Adverse Reaction to Anesthesia __________________
         (Describe __________________________)
                                                                            Any Familial or Inherited Disease _________________




Medications:

Please list all medications that you are currently taking (over the counter, prescriptions and herbal products).
                                                         Patient History

Name                             Dose                          How Often?               Why do you take this?


i.e. Vitamin C                    500 mg                        1 a day                 Prevent colds




Additional medications please note on the back of this form.

What is your occupation or major activity?_________________________________________________________________________

Are you on a special diet? What is it? _____________________________________________________________________________

Do you do regularly exercise or perform heavy labor, please describe: ___________________________________________________

Do you smoke? How much? __________________________________ How many years?__________________________________

Do you drink Alcohol? What type of drinks do you have? ______________________________ How much in one week?___________




Physician Signature: ____________________________________________________ Date: ________________________________



RESPONSIBLE PARTY INFORMATION: Complete this section only if someone other than the patient is financially responsible.
Relationship to patient: Parent Legal Guardian Other ____________________________________
Name: ________________________________________________________Social Security # ________________________________
Sex M F        Date of birth ____/____/____     Age: _____ Marital Status: Single Married Divorced Widowed
Home Address: ______________________________________City: ____________________ State: _____________ Zip: _________
Home Phone: ( ) _______________________ Work ( ) _________________________ Cell ( ) ____________________________
                                                           Patient History

Employed by: _________________________________ Address: _______________________________________________________
____________________________________________________________________________________________________________
**Primary Health Insurance or Injury Related Coverage**
Is this an industrial accident: Yes No If yes, Date of Injury: ____/____/____ Employer: _____________________________
Adjustor or case worker’s name: __________________________________________ Phone # ( ) ____________________________
Is this an auto accident: Yes No If yes, Date of accident: ____/____/____ State where accident occurred: _______________
At what hospital were you treated for your accident? _________________________________________________________________
Name of Insurance: _______________________________Policy # __________________ Group # _______________ Co-pay ______
Insurance Address: ____________________________________City: ____________________ State: __________ Zip: ___________
Insurance Phone #: _____________________________________ Plan effective date :____/____/____
Policy Holder (If not the patient): ________________________________________________________________________________
Policy Holder’s Social Security #: _____________________________________ Sex M F                       Date of Birth ____/____/____
Employed by: _____________________________________________________ Policy holder contact # ( ) ____________________
____________________________________________________________________________________________________________
**Secondary Health Insurance**
Name of Insurance: _______________________________Policy # __________________ Group # _______________ Co-pay ______
Insurance Address: ____________________________________City: ____________________ State: __________ Zip: ___________
Insurance Phone #: _____________________________________ Plan effective date :____/____/____
Policy Holder (If not the patient): ________________________________________________________________________________
Policy Holder’s Social Security #: _____________________________________ Sex M F                       Date of Birth ____/____/____
Employed by: _____________________________________________________ Policy holder contact # ( ) ____________________
____________________________________________________________________________________________________________
**Third Health Insurance**
Name of Insurance: _______________________________Policy # __________________ Group # _______________ Co-pay ______
Insurance Address: ____________________________________City: ____________________ State: __________ Zip: ___________
Insurance Phone #: _____________________________________ Plan effective date :____/____/____
Policy Holder (If not the patient): ________________________________________________________________________________
Policy Holder’s Social Security #: _____________________________________ Sex M F                       Date of Birth ____/____/____
Employed by: _____________________________________________________ Policy holder contact # ( ) ____________________


Patient Name: ___________________________________________________________________ Chart # _______________________________________________

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