Denise Ortega Sanderson, M.D. Patient Information Sheet Name: ________________________________________________________________________________________ (First) (Middle) (Last) Address: ______________________________________________________________________________________ City: _______________________________ State: _______________________ ___Zip: _______________________ Race: ________________________ Ancestry: ______________________ Religion (optional) __________________ Language: ______________ __Social Security Number: _______________________Birthdate: _________________ Home Phone: ______________________ Work Phone: ____________________ Marital Status: S M W D Cell Phone: _________________________________ __ Email: __________________________________________ Emergency Contact: __________________________________ Phone: ____________________________________ Referring M.D._______________________________________Family M.D. ________________________________ Pharmacy Name: _________________________________ Address: ______________________________________ Phone Number: ____________________________________ Fax: ________________________________________ Do you have an advanced directive? _____Living will _____DNR Power of Attorney _____________________ Special Instructions explain if necessary______________________________________________________ Insurance Information: Primary: _______________________________________Secondary: ______________________________________ Policy Holder (If other than self): __________________________________________________________________ D.O.B. ___________________ _________________ Relationship: ___________________ ____________________ I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO DR. DENISE SANDERSON. I REALIZE THAT I AM RESPONSIBLE TO PAY NON-COVERED SERVICES (INCLUDING COLLECTIN COSTS IN THE EVENT OF DEFAULT). A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS VALID AS ORIGINAL. I FURHTER AUTHORIZE RELEASE OF MEDICAL INFORMATION TO SECURE PAYMENT. Patient Signature: ____________________________________________ Date: _____________________________ Denise Ortega Sanderson, M.D. CONSENT AGREEMENT By signing this form, you are granting consent to Dr. Denise Sanderson, M.D. to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full. You have a right to request us to amend your protected health information for the purposes of treatment, payment or health care operations, in writing, explaining your reasoning for the amendment. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement. I understand and authorize, that at times it will be necessary for Dr. Sanderson and/or Staff to call my home or place of business and leave messages on an answering machine, voice mail or e-mail. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your request. I fully understand and ACCEPT the terms of this consent. ____________________ I fully understand and DECLINE the terms of this consent. ____________________ Signature: _________________________________________________________________ Date: ______________________________________________________________________ Family and Friend Release of Information I give permission to allow into the exam room, discuss my care with, and release information to the following listed individuals. NAME RELATIONSHIP _______________________________________________________ Patient’s Name Printed _______________________________________________________ Signature/Date PHONE NUMBER REVIEW OF SYSTEMSBelow is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems may affect your overall course of care, as well as be signs of less than optimal function. Check those that you have experienced in the past and those that you are currently experiencing. Constitutional Heart & Circulation Kidneys/Urinary Tract ____ Chills ____ Daytime drowsiness ____ Fatigue ____ Fever ____ Night sweats ____ Weight gain ____ Weight loss ____ Heart attack ____ High blood pressure ____ Heart murmur ____ Chest discomfort (angina) ____ Heart failure or fluid on the lungs ____ Palpitations, racing or pounding ____ Shortness of breath w/ activity ____ Stroke/mini stroke or TIA ____ Blood clot in artery or vein ____ “Black out spells” ____ Aneurysm of any blood vessel ____ Swelling of legs ____ Heart Surgery ____ Kidney disease or failure ____ History of kidney dialysis ____ Kidney stones or infection ____ Pain/burning with urination _____ Trouble starting urinary stream ____ Dribbling or incontinence ____ Frequent Night Urination ____ Bladder infections during past yr ____ Blood in urine during past yr Eyes ____ Wear glasses OR Contacts ____ Blindness ____ Cataracts ____ Glaucoma Muscles/Bones/Joints ____ Arthritis or other joint disease ____ Chronic back trouble ____ Bone or joint surgery in past year Ears/Nose/Throat Stomach/Intestines ____ Difficulty/Loss of hearing ____ Ringing in the ears (tinnitus) ____ Frequent ear aches ____ Discharge from the ear ____ Attacks of vertigo ____ Sinus trouble ____ Nasal blockage ____ Frequent sneezing ____ Frequent sore throat ____ Snoring ____ Recent change in voice quality ____ Sleep apnea ____ Difficulty in swallowing ____ Nose bleeds ____ Ulcer ____ Frequent heartburn or indigestion ____ Hiatal hernia and or acid reflux ____ Poor appetite ____ Gall bladder attacks ____ Frequent diarrhea ____ Chronic constipation ____ Bright blood bowels or rectum ____ Abnormal stool ____ Liver disease or jaundice Nervous System Endocrine/Metabolism ____ anxiety ____ loss or change in appetite ____ behavioral change ____ bi-polar disorder ____ confusion ____ convulsions ____ depression ____ insomnia ____ memory loss ____ mood change Respiratory ____ Asthma or wheezing ____ Recent bronchitis or chest cold ____ Cough ____ coughing up blood ____ Shortness of breath ____ COPD ____ Thyroid disorder ____ Unusual hair loss or growth ____ goiter ____ Diabetes Blood ____ Bleeding or bruising tendency ____ Previous blood transfusion ____ History of hepatitis ____ Migraines ____ Epilepsy or seizures ____ Date of last seizure: ___________ ____ Depression ____ Other nervous disorder Specify: _________________________ Psychologic ________________________________ Initial ________________________________ Date Allergies (Please list your drug allergies, include latex or adhesive allergies as well) _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Social History _____ Single _____ Married _____ Divorced _____Separated _____ Widowed Work History (Optional) _____ Employed _____ Unemployed _____ Disabled _____ Retired _____ Self Employed Habits Tobacco _____ Yes (How Much) ________________ _____ No ______Quit Alcohol _____ Yes (How Much) ________________ _____ No ______Quit Caffeine _____ Yes (How Much) ________________ _____ No ______Quit Recreational Drugs _____ Yes (How Much) ________________ _____ No ______Quit Family History (Please list family medical conditions) Mother ____________________________________________________________________________________ Father ____________________________________________________________________________________ Sisters ____________________________________________________________________________________ Brothers ____________________________________________________________________________________ Other _____________________________________________________________________________________ Gynecological History Age you started period __________ Are you still having periods? __________ Your last Period:_________________ If yes, are they regular: ____________ If no, how old were you when they stopped? _________________________ Why did they stop? Menopause: _____________ Hysterectomy: ______________ Ablation: __________________ Number of pregnancies: __________ Number of live births: __________ Did you breast feed: _________________ How old were you when you had your first child? ______________________________________________________ Hormone Replacement Therapy (Yes/No, how long?) ___________________________________________________ Oral Contraceptives (Yes/No, How long?) _____________________________________________________________ Breast History Why are you here today? ___I feel something in my breast ___Abnormal Mammogram or Ultrasound ___Skin changes on breast ___My doctor feels something in my breast ___Breast Pain ___Other Have you ever had a biopsy? ___ yes ___ No If so what were the results? ___ Malignant (Cancer) ___ Benign (It was NOT cancer) Which Breast? ___ Right ___ Left Have you ever had breast surgery? ___ yes ___ No What Type? ___________________________________________________________________________ Medical History Surgical History (Please list all medical conditions past and present and any prior surgeries) _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Medications and Dose (Including vitamins & supplements) _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________