Registration Forms

MARIA CHRISTINE BAYANG, M.D.

MUHAMMAD N. LONGI, M.D.

MOAZZAM SAEED, M.D.

300 Read Street, Suite D - Lockport, IL 60441

Telephone: (815) 838-7337 Fax: (815) 838-5007

215 Remington Blvd, Bolingbrook, IL 60440

Date

Home Phone

Cell Phone

PATIENT INFORMATION

Last Name

First Name

Middle Initial

E-mail

SS/HIC/Patient ID #

Address

City

State

Zip

Sex

Male Female

Age

Birthdate

In case of emergency who should be notified?

Phone

PRIMARY INSURANCE

Person Responsible for Account

Last Name

First Name

Middle Initial

Relation to Patient

Birthdate

Soc. Sec. #

Address (If different from patient's)

Phone

City

State

Zip

Person Responsible Employed by

Occupation

Business Address

Business Phone

Insurance Company

Contract #

Group #

Subscriber #

Names of other dependents covered under this plan

ADDITIONAL INSURANCE

Is patient covered by additional insurance?

Yes No

Subscriber Name

Birthdate

Relation to Patient

Address (If different from patient's)

Phone

City

State

Zip

Subscriber Employed by

Business Phone

Insurance Company

Soc. Sec. #

Contact #

Group #

Subscriber #

Names of other dependents covered under this plan

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assign directly to

Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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, Parent, Guardian or Personal Representative

Date

Relationship to Patient

Initial History Questionnaire

Form Completed By

Date Completed

Household

Please list all those living in the child's home.

Add new row

Birth History

Birth weight

Was the delivery

Vaginal Cesarean

Was the baby born at term?

Early?

Late?

If cesarean, why?

If early, how many weeks' gestation?

Did your baby have any problems right after birth?

Yes No

Explain

Did mother have any illness or problem with her pregnancy?

Yes No

Explain

Was initial feeding

Breast

Bottle

During pregnancy, did mother :

Smoke

Yes No

Drink alcohol

Yes No

Did your baby go home with mother from the hospital?

Yes No

Explain

Use drugs or medications

Yes No

What

When

General

Do you consider your child to be in good health?

Yes No

Explain

Does your child have any serious illness or medical condition?

Yes No

Explain

Has your child had serious injuries or accidents?

Yes No

Explain

Has your child had any surgery?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Explain

Is your child allergic to any medicines or drugs?

Yes No

Explain

Family History

Have any family members had the following:

Deafness

Yes No

Who

Comments

Nasal allergies

Yes No

Who

Comments

Asthma

Yes No

Who

Comments

Tuberculosis

Yes No

Who

Comments

Heart disease (before 50 years old)

Yes No

Who

Comments

High Blood Pressure (before 50 years old)

Yes No

Who

Comments

High cholesterol

Yes No

Who

Comments

Anemia

Yes No

Who

Comments

Bleeding disorder

Yes No

Who

Comments

Liver disease

Yes No

Who

Comments

Kidney disease

Yes No

Who

Comments

Diabetes (before 50 years old)

Yes No

Who

Comments

Bed-wetting (after 10 years old)

Yes No

Who

Comments

Epilepsy or convulsions

Yes No

Who

Comments

Alcohol abuse

Yes No

Who

Comments

Drug abuse

Yes No

Who

Comments

Mental illness

Yes No

Who

Comments

Mental retardation

Yes No

Who

Comments

Immune problems. HIV. or AIDS

Yes No

Who

Comments

Additional family history

Past History

Does your child have, or has he/she ever had:

Chickenpox

Yes No

When

Frequent ear infections

Yes No

Explain

Problems with ears or hearing

Yes No

Explain

Nasal allergies

Yes No

Explain

Problems with eyes or vision

Yes No

Explain

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

Explain

Any heart problem or heart murmur

Yes No

Explain

Anemia or bleeding problem

Yes No

Explain

Blood transfusion

Yes No

Explain

Frequent abdominal pain

Yes No

Explain

Constipation requiring doctor visits

Yes No

Explain

Bladder or kidney infection

Yes No

Explain

Bed-wetting (after 5 years old)

Yes No

Explain

(For girls) Has she started her menstrual periods?

Yes No

Explain

(For girls) Are there problems with her periods?

Yes No

Explain

Any chronic or recurrent skin problem (acne. eczema. etc)

Yes No

Explain

Frequent headaches

Yes No

Explain

Convulsions or other neurologic problem

Yes No

Explain

Diabetes

Yes No

Explain

Thyroid or other endocrine problem

Yes No

Explain

Any other significant problem

Yes No

Explain

Use of alcohol or drugs

Yes No

Explain

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