New Patient Packet

Patient Profile

Full Name

Marital Status

Address

City

State

Zip

Cell Phone

Home Phone

Sex

Male Female

DOB

Age

Social Security Number

Referred By

Next of Kin:

Name

Phone

Relationship

Address

Insurance Information

Insurance

Policy #

Policy Holder's Name

Relationship to Policy Holder

Self Spouse Son Daughter

Self Pay

I authorize CHARM CITY HEALTHCARE, LLC to apply for benefits rendered. I request payment from my insurance company to be made directly to them. I certify that the information I have reported concerning my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of authorization to be used in place of the original. The authorization may be revoked by me at anytime in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided when a statement is rendered.

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 Subscriber or Beneficiary

Date

Authorization for Medical Records Release

Patient Information

Request Release Information From

Name

Address

City/State/Zip

DOB

SSN

I hereby authorize you to release Charm City Health Care, LLC a copy of my medical records to be used for continuing medical care. I reserve the right to revoke the authorization in writing at any time. I further agree and understand that this protected health information may be re-disclosed by the recipient and thus, no longer protected under privacy rules.

Patient or Guarantor Signature

Date

Remarks

Thi authorization will expire on

Notice of Privacy Practices

OBJECTIVES:

The management of all patient information in the strictness of confidence.

CONFIDENTIAL ISSUES:

Medical Charts
Insurance claims and billing issues
Telephone calls (inclusive of appointment conformation, lab results, and/or any other necessary information)
Prescription instruction, changes in medications, and/or notifying pharmacies of new medications
Release of records for specialists, and/or other personal requests
Requisitions for lab work, x-rays, other test, and referrals to other specialists
Disclosure permitted to physicians, family member, and/or other of you healthcare information

PERMISSION

Yes No

Signature

Date

Print Name

Please be advised that your signature is valid for six (6) years unless written notification has been submitted to DR. PANKAJ KHETERPAL.

New Patient Health Questionnaire

Name

Date

DOB

Age

PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.

What medical concerns bring you to our office?

Occupation

Have you ever smoked?

Yes No

Do you still smoke now?

Yes No

Medical Information

Allergies: Are you allergic to any drugs?

Yes No

If yes, please list.

Medications (list all medications you are taking regularly. Include over the counter, herbal or natural remedies.)

Medical Illnesses or Conditions

Cancer: Specify Type

Operations (Please list any surgery and approx. year)

Add new row

Hospitalization in the last 12 months (other than surgeries)

Add new row

Family Medical History

Father

Age

Medical Issues

If deceased, age at death and cause, if known.

Mother

Age

Medical Issues

If deceased, age at death and cause, if known.

Brother or Sister

Age

Medical Issues

If deceased, age at death and cause, if known.

Immunizations (Check if Yes and indicate year of last injection)

Influenza

Yes No

Year

Pneumonia

Yes No

Year

MMR

Yes No

Year

Tetanus

Yes No

Year

Shingles

Yes No

Year

Other

Yes No

Year

Females Only: Are you pregnant, planning a pregancy or nursing a child?

Yes No

Date of last mentrual period?

Systems Review:

Please indicate those items that have been a recurrent or a recent significant change.

Constitutional Systems

Good health lately

Yes No

Recent significant weight change

Yes No

Unusual fatigue or weakness

Yes No

Frequent headaches

Yes No

Eyes

Change in vision

Yes No

Blurred or double vision

Yes No

Eye disease or injury

Yes No

Wear glasses/contact lenses?

Yes No

Ears/Nose/Mouth/Throat Neck

Do you wear hearing aids?

Yes No

Hearing loss or ringing in ears?

Yes No

Earaches or drainage?

Yes No

Chronic sinus problems or runny nose

Yes No

Nose bleeds

Yes No

Mouth sores

Yes No

Bleeding gums

Yes No

Sore throat/hoarseness or voice change

Yes No

Lumps or swollen glands in neck

Yes No

Difficulty swallowing

Yes No

Neck pain or stiffness

Yes No

Radio buttons

Yes No

Cardiovascular

Heart trouble

Yes No

Chest pain or angina

Yes No

Palpitations

Yes No

Shortness of breath with walking or lying flat

Yes No

Swelling feet, ankles, or hands

Yes No

Walking at night with shortness of breath

Yes No

Respiratory

Chronic or frequent cough

Yes No

Coughing or spitting up blood

Yes No

Shortness of breath

Yes No

Asthma or COPD

Yes No

Gastrointestinal

Recent loss of appetite

Yes No

Recent change in bowel movements

Yes No

Painful bowel movements or constipation

Yes No

Frequent stools

Yes No

Rectal bleeding or blood in stool

Yes No

Stomach/Abdominal pain or heartburn

Yes No

Black or tarry stools

Yes No

Psychiatric

Memory loss

Yes No

Genitourinary

Frequent urination

Yes No

Burning or pain in urination

Yes No

Blood in urine

Yes No

Change in force or strain in urinating

Yes No

Incontinence or dribbling of urine

Yes No

MEN: Testicular pain

Yes No

WOMEN: Painful periods

Yes No

WOMEN: Irregular periods

Yes No

WOMEN: Recurrent vaginal discharge

Yes No

Number of pregnancies (including miscarriages)

Pregnancies

Miscarriages

Method of birth control (if applicable)

Date of last menstrual period

Year of last pap smear

Year of last mammogram

Musculoskeletal

Joint pain(s)

Yes No

Joint stiffness/swelling

Yes No

Weakness of muscles

Yes No

Muscle pain

Yes No

Back pain

Yes No

Difficulty in walking

Yes No

Integumentary (Skin/Breast)

Rashes or itching

Yes No

Change in skin color or moles

Yes No

Change in hair or nails

Yes No

Varicose veins

Yes No

Neurological

Frequent, recurring or increasing headaches

Yes No

Light-headedness or dizziness

Yes No

Convulsions, seizures, or spasms

Yes No

Numbness or tingling sensation

Yes No

Tremors

Yes No

Mini Stroke (TIA)

Yes No

Insomnia

Yes No

Depression

Yes No

Endocrine

Heat or cold intolerance

Yes No

Excessive skin dryness

Yes No

Excessive thirst or urination

Yes No

Hematology

Slow to heal after cuts or wounds. Bleeding or bruising tendency

Yes No

Anemia

Yes No

Clotting Disorder

Yes No

Comments

Patient Signature

Date

Reviewed By

Date

Physician Signature

Date

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