Please Check the appropriate boxes to identify any previous major surgical procedures.
∗
∗
∗
∗
∗
∗
∗
Appendectomy
Gallbladder Removal
Ulcer Surgery
Removal of portion of the stomach
Colon Resection
Hiatal Hernia Repair
Hysterectomy
Removal of Tubes and Ovaries
Coronary Bypass (CABG)
Heart Valve Replacement
Aortic Aneurysm Repair
Angioplasty/Stent Replacement
Other: ________________________________
Have you been diagnosed with the following:
Coronary Heart Disease---------------------------------------------------------------------------------YES NO
Valvular Heart Disease ---------------------------------------------------------------------------------YES NO
Hypertension (high blood pressure) ---------------------------------------------------------------YES NO
Stroke -------------------------------------------------------------------------------------------------------YES NO
Chronic Bronchitis ---------------------------------------------------------------------------------------YES NO
Emphysema------------------------------------------------------------------------------------------------YES NO
Asthma -----------------------------------------------------------------------------------------------------YES NO
Tuberculosis-----------------------------------------------------------------------------------------------YES NO
Anxiety------------------------------------------------------------------------------------------------------YES NO
Depression-------------------------------------------------------------------------------------------------YES NO
Elevated Cholesterol ------------------------------------------------------------------------------------YES NO
Elevated Triglycerides ----------------------------------------------------------------------------------YES NO
Hiatal Hernia ----------------------------------------------------------------------------------------------YES NO
GERD --------------------------------------------------------------------------------------------------------YES NO
Gallstones -------------------------------------------------------------------------------------------------YES NO
Duodenal Ulcer ------------------------------------------------------------------------------------------YES NO
Gastric Ulcer ----------------------------------------------------------------------------------------------YES NO
Pancreatitis -----------------------------------------------------------------------------------------------YES NO
Hepatitis A / B / C (circle one) -----------------------------------------------------------------------YES NO
Ulcerative Colitis -----------------------------------------------------------------------------------------YES NO
Crohn’s Disease ------------------------------------------------------------------------------------------YES NO
Epilepsy ----------------------------------------------------------------------------------------------------YES NO
Anemia -----------------------------------------------------------------------------------------------------YES NO
Diabetes----Type I or Type II --------------------------------------------------------------------------YES NO
Hypothyroidism ------------------------------------------------------------------------------------------YES NO
Hyperthyroidism -----------------------------------------------------------------------------------------YES NO
*Cancer-----------------------------------------------------------------------------------------------------YES NO
*If YES, What Type? ______________________________________________
Please Comment on personal habits as follows:
Do you smoke: YES
NO
If YES:
Packs per day: _______ Years Smoking? _______
Do you use chewing tobacco or snuff? YES NO If YES, How long? _______
Do you drink alcohol? YES
NO
If YES, please answer the following:
Beers per week? _______ Mixed drinks per week? ________ Glasses of Wine per week_______
Marital History: Married Single
Widowed
Separated
Divorced
Living with Partner
Occupation: _______________________________________________________
Rev. 01-02-12
Please indicate below if any or all of your family members have had
the following illnesses using these abbreviations:
M = Mother F = Father S = Sister B = Brother CH= Child MGM = Maternal Grandmother
PGM = Paternal Grandmother, MGF = Maternal Grandfather PGF = Paternal Grandfather
PU = Paternal Uncle MU = Maternal Uncle PA = Paternal Aunt MA = Maternal Aunt
Seizure Disorder: _____________________________
Heart Disease: ____________________________
Colon Cancer/Polyps: __________________________ Diabetes: _________________________________
Liver Disease: ________________________________ Stroke: __________________________________
Bleeding Disorder: _____________________________ Hypertension: _____________________________
Cancer (give type) _____________________________ Lung Disease: _____________________________
Mental Illness: _________________________________ Other: ____________________________________
Please Circle Your Current Problems or Symptoms:
Constitutional:
Fatigue
Skin:
Itching
Rash
Eyes:
Pain
Redness
HENMT:
Headache
Weight loss
Vertigo
Nose Bleeds
Blurred Vision
Light-Headedness Tinnitus (ringing) Hearing Loss
Sore Tongue
Respiratory:
Chronic Cough
Cardiovascular:
Irregular Heart Beat
Hoarseness
Sores
Production of Sputum Pain aggravated by deep breathing
∗
Aching/Squeezing Chest Pain:
∗
Shortness of Breath:
Genitourinary:
Weight Gain
Ankle Edema
With Exertion
With Exertion
Blood in Urine
Leg Pain with Walking
At Rest
At Rest
Incontinence
(Males) Impotence
(Females) Abnormal Menstrual Bleeding
Lymph:
Fever
Hematologic:
Bruise Easily
Musculoskeletal:
Painful Muscles
Neurologic:
Numbness
Endocrine:
Excess Urination
Psychiatric:
Nervousness
Painful Periods
Night Sweats
Bleed Easily
Painful Joints Swelling of Joints
Unsteady Gait
Tremor
Intolerance of Heat
Depression
Stiffness of Joints
Muscular Weakness
Intolerance of Cold
Thoughts of Suicide
Insomnia
Irritability
Please list any drug or seasonal allergies and reaction.
Rev. 01-02-12
Berea College Health Service
Financial & Consent to Treat Policy
***Staff/Faculty and Dependents***
Please understand that health insurance is a contract between you and your insurance carrier to
pay for medical care. You are ultimately responsible for you bill regardless of status of the claim.
Payment is due at the time of service. We accept Visa, Mastercard, Personal checks, and Cash. If
unusual circumstances make it impossible to pay, please feel free to discuss this with our office
staff.
You will receive regular statements from our office informing you of the status of your account.
Feel free to call your office should you have any questions. You will also be billed separately by the
hospital for lab fees, and/or outpatient or inpatient procedures. We charge for special forms and
letters to be sent to lawyers, disability boards, auto claims and other physicians. The amount
charges will vary with the amount of paper and time involved.
I have read and understand the above financial policy and give my permission for BCHS to treat
me and bill my insurance for services rendered.
________________________________________________
Signature
_______________________
Date
Rev. 01-02-12
Berea College Health Service
CPO 2174
Berea, KY 40404
Privacy Consent For Use Or Disclosure of Patient Information For Purposes Of Treatment,
Payment, And Healthcare Operations
I hereby consent to Berea College Health Service (BCHS) using or disclosing my protected health
information (PHI) for the purpose of providing treatment to me, obtaining payment for health care
services rendered to me or to carry out the Practice’s health care operations. I also consent to
BCHS using or disclosing my PHI for treatment activities provided by another healthcare provider or
entity. I further consent to the disclosure of my PHI in order for another provider or health care
entity to conduct health care operations including quality assessment and reviewing the
competence of health care professionals.
Specific Records Expressly Included: I expressly authorize release of the following information for
the purposes of treatment, payment and health care operations, if it is part of my protected health
information.
Check Any And All You Agree To Authorize For Release:
Chemical Dependency/Substance Abuse
ο Drugs
ο Alcohol
Sexually Transmitted Diseases
I further acknowledge that BCHS has provided me with a copy of its Notice of Privacy Practices,
which provides a detailed description of the uses and disclosures allowed by this consent, as well as
other rights I have regarding my protected health information.
_________________________________________
Printed Name of Patient
or Personal Representative
_____________________________
Date
____________________________________
Signature of Patient
or Personal Representative
________________________________________
Description of Personal
Representative’s Authority
Rev. 01-02-12