Patient Packet

Authorization Release for Dental Information

Patient’s Name: Last

First:

Middle Initial:

DOB:

Address:

City/State/Zip:

Home/Cell Number:

I hereby authorize (Dentist’s Name):

Address:

City/State/Zip:

Phone Number:

Fax Number:

To release my dental records to:
Melville Medicine
1545 East Southlake Blvd, Suite 110 Southlake, TX 76092
Phone: 817-676-2010 Fax: 817-549-4687

Please send the following information:

Chart notes
Probe chart
Pathogen testing
Cone beam results
NO x-rays/We cannot accept CD’s

I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus) and other sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

I hereby release (Dental Provider’s Name):

and staff from all legal responsibility that may arise from the act hereby authorized.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature:

Date:

Guardian/Legal Representative:

Date:

To be valid, this authorization must be dated within 90 days of the request for the information and can be revoked at any time, providing that the information has not yet been released. No information for medical treatment received after the date of this authorization will be released.

Patient Records of Disclosures

Acknowledgement of Review of Notice of Privacy Practices

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner.
(Please check in each section)

Patient’s Name: Last

First:

Middle Initial:

Home Telephone:

Leave message with detailed information

Leave message with a call-back number

Do not leave a message

Work Telephone:

Leave message with detailed information

Leave message with a call-back number

Do not leave a message

Cell Telephone:

Leave message with detailed information

Leave message with a call-back number

Do not leave a message

Fax Number:

Please do not fax any information

E-Mail:

Please do not E-mail any information

Written Communication:

Mail to my home

Mail to my work/office

Do not mail

BlipCare Monitor / Portal:

Acceptable to access

The following people may have access to my medical information:

No authorized person

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document if requested.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Personal Representative:

Date:

Authorization Release for Medical Information

Patient’s Name: Last

First:

Middle Initial:

DOB:

Address:

City/State/Zip:

Home/Cell Number:

I hereby authorize (Doctor’s Name):

Address:

City/State/Zip:

Phone Number:

Fax Number:

To release my medical records to:
Melville Medicine
1545 East Southlake Blvd, Suite 110 Southlake, TX 76092
Phone: 817-676-2010 Fax: 817-549-4687
Please send the following information:

Most recent complete physical exam
Laboratory tests (last 2 years)
Most recent chest x-ray, EKG, stress test, any cardiovascular tests
Consultation reports from specialists concerning diabetes or cardiovascular disease (last 2 yrs.)
Medication list
Chart notes (last 2 yrs.)

I hereby release (Medical Provider’s Name):

and staff from all legal responsibility that may arise from the act hereby authorized.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature:

Date:

Guardian/Legal Representative:

Date:

2019 PATIENT DEMOGRAPHICS

Date:

Gender:

Male Female

Name: Last

First:

Middle Initial:

Date of Birth:

Social Security Number:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Mailing Address:

City:

State:

Zip:

Marital Status:

Single

Married

Divorced

Widowed

Caregiver for Dependents?

Spouse / Emergency Contact:

Phone Number:

Relationship:

Occupation:

How Long in Profession?

Primary Insurance Company:

ID Number:

Group Number:

Secondary Insurance Company:

ID Number:

Group Number:

Person Responsible for Billing:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s Signature

Health History

Name:

Date:

Date of Birth:

How did you find out about the practice?

Your answers will give us a better understanding of your medical concerns and conditions. If you are uncomfortable with any questions, feel free not to answer them. Best estimates are fine; however, be specific whenever you can. Please contact family members if you need assistance completing the family history section. If you need more space, simply attach as many additional pages as you need. Thank you!

How would you rate your current health?

Excellent Good Fair Poor

Current age:

Weight:

Height:

Ethnicity:

Waist measurement:

Date of your last physical exam::

Medications: Please list all prescription and non-prescription medications, vitamins, home remedies, and herbs.

Medication/Supplements:

Dose (mg per pill, doses per day):

Start date:

Reason:

Add new row for another medication

Blood type:

Allergies or reactions to medicines:

When was your most recent:

Cholesterol screening:

Bone Density Test:

Chest X-ray:

Flu Vaccine:

Lung Function:

Shingles Vaccine:

Colonoscopy:

Pneumovax:

Endoscopy (upper GI):

Dental Exam:

Peripheral Vascular Disease Test (ABI):

Eye Exam:

EKG:

Coronary CT Scan:

CIMT:

Any other vascular test (Please specify):

Health History (continued)

Have you ever been hospitalized for illness?

Yes No

If so, When and Why:

Surgical History

Please list all other operations with the dates when they occurred.

Social History

Tobacco Use

Cigarettes:

Never

Quit

Date you quit smoking:

Current Smoker

Packs per day:

Other Tobacco (check all answers that apply):

Pipe

Cigar

Chewing Tobacco

E-Cigarettes

Marijuana

Number of years you’ve used this tobacco:

Are you interested in quitting?

Yes No

Have you tried to quit in the past?

Yes No

If yes, how many times have you tried to quit?

What methods have you tried?

Are you exposed to second-hand smoke?

Yes No

If yes, for how long?

Alcohol Use

Do you drink alcohol?

Yes No

If yes, how many drinks do you consume per week?

Alcohol Type:

Does your alcohol consumption have you or others concerned?

Yes No

Other Concerns

Caffeine Intake

Coffee (cups/day):

Tea (cups/day):

Sodas per day:

Soda type:

Diet Regular

Decaffeinated products?

Yes No

If yes, specify/how much:

Do you drink energy drinks or take pills to stay awake?

Yes No

If yes, specify:

Chocolate (ounces per day):

Chocolate type:

Dark Light

Weight

Are you satisfied with your weight?

Yes No

What is your goal weight?

When did you last weigh your goal weight?

How long were you at that weight?

Health History (continued)

Exercise

Do you exercise regularly?

Yes No

What kind of exercise?

How long do you exercise in minutes?

How Often?

If you, do not exercise, why not?

Do you have any limitations to your ability to exercise?

Yes No

If yes, please explain:

Oral Health

How many times per day do you brush your teeth?

What type of toothbrush do you use?

Do you floss regularly?

Yes No

How often?

Do you ever have bleeding gums?

Yes No

How often do you see your dentist?

Does your oral health concern you?

Yes No

If yes, why?

Stress

How would you classify your stress level at work?

Low Medium High

How would you classify your stress level at home?

Low Medium High

Do you feel anxious, angry, irritated, or rushed?

Yes No

How do you manage your stress?

List ways for which you relax?

Do you meditate daily?

Yes No

If yes, how?

Do you perceive a lack of control of your environment?

Yes No

If yes, why?

Diet

How do you rate your diet?

Good Fair Poor

Do you currently see a dietitian? If yes, how often?

Name/Contact Information:

How many daily servings of the following do you have:

Whole grains

Water

Fruit

Nuts

Vegetables

Milk

What %:

How many times a week do you consume the following items?

Eggs

Fish

Margarine

Chicken/Turkey

Dairy Products

Red Meat

Fried Foods

Butter

Processed Foods

Going out to Eat

Do you have any food allergies or food sensitivities?

Yes No

If yes, please explain:

Travel History

Any Recent International Travel?

Yes No

If yes, What countries and dates of stay?

Any illness during or post travel?

Health History (continued)

History for Men:

Do you have problems with erections?

Yes No

If yes, date of onset?

Do you have problems with sexual desire or sex drive?

Yes No

If yes, date of onset?

Do you have problems with sexual satisfaction?

Yes No

If yes, date of onset?

Do you have problems with decreased energy? Or decrease muscle strength?

Yes No

If yes, date of onset?

Have you used testosterone injection/pelleting?

Yes No

If yes, date(s) started/ended?

Testosterone Dose/Frequency:

History for Women:

How many times have you been pregnant?

How many deliveries?

Miscarriages?

Please list any problems you have experienced with pregnancy or delivery:

Do you have osteoporosis (Bone Loss)?

Yes No

Osteopenia (Bone Thinning)?

Yes No

When was the first day of your most recent period?

What was your age at your first period?

Frequency of periods:

Length of each:

Are your periods:

Regular Irregular

Menopause?

Yes No

Hysterectomy?

Yes No

If yes, when?

Ovaries Removed?

Yes No

Do you have any history of gestational Diabetes?

Yes No

High Blood Pressure or Eclampsia with pregnancy?

Yes No

Did any of your children weigh more than eight pounds at birth?

Yes No

Do you have problems with sex drive?

Yes No

If yes, date of onset?

Do you have problems with sexual satisfaction?

Yes No

If yes, date of onset?

Have you used hormone replacement therapy?

Yes No

If yes, date of onset?

Name of hormone replacement therapy medication/method:

Dose/Frequency of hormone replacement therapy:

Health History (continued)

Review of Symptoms

Please check any current problems you have on the list below.

Respiratory:

Cough/Wheeze

Difficulty Breathing

Snoring

Sleep Apnea/CPAP Frequent

Respiratory Infections

Eyes:

Dry Eyes

Frequent Irritation

History of Retinal Tear or Hemorrhages

Double Vision

Change in Vision

Explain:

Glaucoma

Treatment?

Cataracts

Surgery?

Ear/Nose/Throat/Mouth:

Difficulty Hearing/Ringing in Your Ears

Hay Fever/Allergies

Bleeding Gums

Dental Implants

Cardiovascular:

Chest Pain/Discomfort

Palpitations (Irregular Heartbeat)

Swelling in Feet/Legs

Varicose Veins

Pain in the Extremities with Exercise

Skin:

Acanthosis Nigricans (Dark Lines Around Neck)

Skin Tags

Flattening of Nail Beds

Creases in Earlobes

Frequent Itching of Skin

Skin Infections

Genitourinary:

Unusual Frequency of Urination

Increased Urination at Night that Interrupts Sleep

Blood in Urine

Gastrointestinal:

Abdominal Pain

Blood in Bowel Movement

Heartburn

Nausea/Vomiting

Diarrhea/Constipation

Loss of Appetite

Weight Loss

Weight Gain

Neurological:

Headaches

Light-Headedness

Memory Loss

Loss of Coordination

Tingling, Pain, or Numbness in Hands or Feet

Any other symptoms? If so, please list them:

Health History (continued)

Family History

Please indicate the current status of your immediate family members. Include if each person is alive or deceased; the person’ age now and or at the time of death; if applicable, the cause of death; and any other relevant comments.

Mother’s Mother:

Mother’s Father:

Father’s Mother:

Father’s Father:

Mother:

Father:

Sister:

Add new row for another sister

Brother:

Add new row for another brother

Daughter:

Add new row for another daughter

Son:

Add new row for another son

Please use this space to list any additional family members:

Health History (continued)

Medical Condition

2019 Physician/Provider Information Form

Patient’s Name: Last

First:

Middle Initial:

Your Primary Care Provider:

Specialty:

Last Visit:

Frequency of Visits:

Telephone:

Fax:

Address:

Dental Provider:

Specialty:

Last Visit:

Frequency of Visits:

Telephone:

Fax:

Address:

Other Specialist Provider:

Specialty:

Last Visit:

Frequency of Visits:

Telephone:

Fax:

Address:

Add new row for another specialist provider

Notice of Privacy Practices

We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this office, whether made by your personal medical provider or others working this office. This notice will inform you about the ways we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

Make sure that health information that identifies you is kept private.
Give you this notice of our legal duties and privacy practices with respect to health information. Follow the terms of the Notice of Privacy Practices that is currently in effect.

How we may use and disclose health information about you:

For treatment, for payment, for health care operations, for appointment reminders, as required by law, public health risks, health oversight activities, lawsuits and disputes, law enforcement, coroners, health examiners and funeral directors, to avert a serious threat to health and safety, as required by the military or veterans administration, national security, inmates, workers’ compensation.

Your rights regarding health information about you:

Right to inspect and copy, right to amend, right to an accounting of disclosures, right to request restrictions, right to request confidential communications, right to a paper copy of this notice.

Changes to Notice of Privacy Practices:

We reserve the right to change this notice. We will post a copy of the current notice in our facility with the current effective date.

Complaints:

If you believe that your privacy rights have been violated you may file a complaint with us. All complaints must be in writing.

Acknowledgment of Receipt of this Notice:

We will request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgment will become part of your records.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Health History (continued)

Personal Medical History

Please Indicate if whether you had any of the following medical problems.
(Include dates to indicate when the problem occurred.)

Heart Disease

Dates:

Stroke

Dates:

High Blood Press

Dates:

High Cholesterol

Dates:

Pre-Diabetes

Dates:

Diabetes

Dates:

Mini-Stroke of TIA

Dates:

Atrial Fibrillation

Dates:

Poor Blood Flow to Extremities

Dates:

Poor Blood Flow to Intestines

Dates:

Poor Blood Flow to Kidneys

Dates:

Aortic Aneurysm

Dates:

Brain Aneurysm

Dates:

Bleeding/Clotting Problems

Dates:

Blood Transfusion

Dates:

Anemia

Dates:

High Red Blood Cell Count

Dates:

Leukemia

Dates:

Abnormal Platelet Count

Dates:

Heart Arrhythmia

Dates:

Heart Valve Problem

Dates:

Rheumatoid Arthritis

Dates:

Kidney Disease

Dates:

Kidney Stones

Dates:

Gallbladder Stones

Dates:

Pancreatic Disease

Dates:

Fatty Liver

Dates:

Lupus

Dates:

Psoriasis

Dates:

Sjogren’s Syndrome

Dates:

Autoimmune Disorder

Dates:

Periodontal Disease

Dates:

Dental Infections

Dates:

Root Canal

Dates:

Bleeding Gums

Dates:

Gout

Dates:

Polycystic Ovaries

Dates:

Thyroid Problems

Dates:

Depression

Dates:

Suicide Attempts

Dates:

Anxiety/Panic Attacks

Dates:

Migraine Headaches

Dates:

Thin Bones/Osteoporosis

Dates:

Stomach Ulcers

Dates:

Chronic Heartburn

Dates:

Restless Legs

Dates:

Sleep Disorder

Dates:

Hormone Imbalance

Dates:

Toxin Exposure

Dates:

Unexplained Nerve Problems

Dates:

Cancer

Dates:

Physical Disability

Dates:

Mental Disability 1

Dates:

Mental Disability 2

Dates:

Post-Traumatic Stress Syndrome

Dates:

Celiac Disease

Dates:

Diverticulosis

Dates:

Irritable Bowel Syndrome

Dates:

Gluten Intolerance

Dates:

Blood Clots in Legs

Dates:

Hodgkin’s Disease

Dates:

History Hepatitis

Dates:

Alcoholism

Dates:

Drug Use

Dates:

History AIDS

Dates:

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