New Patient Form

Patient Name:

Date of Birth:

Age:

Gender:

Male Female

MEDICAL HISTORY

Surgical History

Add Surgery

Medication List:

Add Medication

Drug Allergies:

Add Drug Allergies

Social History:

Smoking:

Yes No

How man packs a day:

Did you quit smoking:

Yes No

What year did you quit:

When did you start:

Illegal Drug Use:

Any marijuana use:

Yes No

Any drug use:

Yes No

History of drug abuse:

Yes No

Alcohol Use:

Any alcohol use:

Yes No

History of alcohol abuse:

Yes No

How many drinks in a day:

How many days per week:

Married?

Yes No

Occupation:

Currently working:

Yes No

Retired:

Yes No

If yes, when?

Disabled?

Yes - Permanent Yes - Partial No

Any stairs in your home:

Yes No

Any stairs in your home:

How many persons live in household:

How many animals in home?

Review of Systems:

Associated Symptoms

Pain:

Bending backwards

Increases Decreases No Change

Bending forward

Increases Decreases No Change

Changes in weather

Increases Decreases No Change

Climbing stairs

Increases Decreases No Change

Coughing/sneezing

Increases Decreases No Change

Driving

Increases Decreases No Change

Lifting objects

Increases Decreases No Change

Looking upward

Increases Decreases No Change

Looking downward

Increases Decreases No Change

Rising from seated position

Increases Decreases No Change

Sitting

Increases Decreases No Change

Standing

Increases Decreases No Change

Walking

Increases Decreases No Change

Numbness/tingling

Increases Decreases No Change

Weakness in the arm/leg

Increases Decreases No Change

Balance problems

Increases Decreases No Change

Bladder incontinence

Increases Decreases No Change

Bowel incontinence Joint

Increases Decreases No Change

Swelling/Stiffness

Increases Decreases No Change

Fevers/chills

Increases Decreases No Change

Mark Treatments

Surgery

Yes No

Physical Therapy

Yes No

Chiropractic Care

Yes No

Brace

Yes No

Psychological Therapy

Yes No

NSAIDs (ibuprofen, Aleve, Mobic, etc)

Yes No

Date

Name:

Date of Birth:

I hereby authorize to send my health information to:

Name: Harold J. Bayonne, Jr. MD

Address: 1613 Louisville Ave., Monroe, LA 71201

Phone: 318-855-3291 | Fax: 318-737–7039

Scope of information to be released:

All information regarding assessment, diagnosis, and treatment of patient's condition, concerns, or disease

Specify:

All information regarding care received by patient between the dates of (input below) and (input below) All alcohol and drug use treatment Other information (specify)

All information regarding care received by patient between the dates

of:

and:

If other, Please specify:

Signature of Patient or Legally Responsible Party:

Name (Please Print)

Relationship/Reason why patient is unable to sign:

Date:

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed how you can get access to this information. Please review the following information carefully. Your health information contains personal information about you and your health and is referred to as protected health information "PHI ". This information contains details that can be used to identify you and any information we have created or received regarding your past, present, or future conditions. This notice describes how we may use or disclose your PHI in accordance with applicable law. We are legally required to maintain the privacy of PHI and to provide you with notice of legal duties and privacy practices with respect PHI. We are required to abide by these terms of this Notice of Privacy Practices. We reserve the right to change in terms of this notice at any time. Any changes to this notice will be effective for all PHI we have at that time. The new privacy practices will be available upon request.

How we may use an disclosure of PHI:

For treatment: Your pH may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your healthcare treatment and related services.

For payment: We may use and disclose PHI so that we can receive payment for the treatment services provided to you.

For Healthcare operation: We may use or disclosure PHI for our healthcare operations. This might include measuring quality of care, licensing is and/or certifications to continue providing quality care. Required by law: We may disclosure PHI will require bilateral without your approval. Examples of when this may happen include abuse, neglect, domestic violence, emergencies, judicial or administrative proceeding, public safety risk, etc.

Your Rights Regarding your PHI:

You have the following rights regarding PHI we maintain about you. Please submit your request in writing to Harold Bayonne Jr, MD APMC, 1613 Louisville Ave., Monroe, LA 71201 or fax 318-737-7039

Right to request limits on uses and disclosure. You have the right to request how we use or disclosure PHI.

Right to access and received copies. You have the right, in most cases, to review and receive copies of your PHI. A request must be submitted in writing to Harold Bayonne Jr, MD APMC. 1613 Louisville Ave., Monroe, LA 71201 or fax: 318-737-7039. You may be charged a fee for copies made.

Right to amend. If you feel your PHI is incorrect and complete, you may request your PHI be amended. You must request in writing what is to be amended and why to Harold J Bayonne Jr, MD APMC.

Right to request confidential communication. You have the right to request that we communicate with you in a certain way or at a certain location.

Right to a copy of this notice. You have a right to a copy of this notice

Acknowledgment of Privacy Practices

I,(Please, input Name below) acknowledged that I have received a copy of the Notice of Privacy Practices from Harold Bayonne Jr, MD APMC

I have listed individuals that are hospitalized to receive my protected health information. I am aware that I can revoke the authorization for any individual at any time, but must do so in writing.

Signature of Patient:

Date:

Signature of Patient Representative & Relationship

Date:

The following individuals have him my authorization to access my Protected Health Information

Add Name

Referring Physician:

Primary care physician:

Chief complaint (reason for your visit today):

Does this pain radiate?

Yes No

If so, where?

Please list any additional areas of pain:

Approximately when did this pain began?

What caused her current pain episode?

How did your current pain episode begin?

Gradually Suddenly

Since her pain began how has a change?

Improved Worsened Stayed the same

When is your pain at its worst?

Mornings

Daytime

Evenings

Middle of the night

Always the same

Often days or pain occur?

Constant Changes in severity but always present Intermittent

If pain “0” rotation is no pain and “10” is the worst pain you can imagine, how would you rate your pain?

Right now:

The best it gets:

The worst it gets:

Your information will be encrypted.