New Patient Medical History
Date __________
Patient Name______________________________________________ DOB _____________ Age______
Primary Care Physician _________________________________________________________________
Referring Physician _____________________________________________________________________
Other Physicians _______________________________________________________________________
Chief Complaint (reason for your visit today) _______________________________________________________
__________________________________________________________________________________________________
Allergies (please specify symptoms)
__________________________________________________________________________________________
Do you take Aspirin, Plavix, or blood thinner such as Coumadin? (please specify) ____________________
Current Medications
Date
Medication
Dosage
Medical History
Specify if indicated
Cancer
Diabetes
Heart Disease
Lung Disease
Liver Disease
Kidney/Bladder
High Blood Pressure
*Other (please explain)
____________________________________________________________________________________
____________________________________________________________________________________
Past Surgeries
Date and type of surgery
Abdominal
Heart
Head and Neck
OB/Gyn
Breast
Orthopedic
*Other (please explain)
____________________________________________________________________________________
____________________________________________________________________________________
Social History
Type of Employment
Smoking
Yes / No
If Yes, How many
Alcohol Use
Yes / No
If Yes, How many
If previous smoker, year quit _____
Family History (check ALL that apply, Specify if indicated; mother, father, brother, sister)
Cancer
Diabetes
Heart Disease
Lung Disease
Liver Disease
Kidney/Bladder
High Blood Pressure
Other (please explain)
Review of Systems (Please check ALL that apply)
General
Chills
Fatigue
Fever
Headache
Night sweats
Weight loss
Weight gain
Cardiovascular
Chest pain at rest
Chest pain with exercise
Pain in leg muscles when
walking
Difficulty lying flat
Irregular heartbeat
Palpitations
Allergy
Congestion
Hives
Itching
Rash
Gastrointestinal
Abdominal pain
Blood in stool
Change in bowel movements
Constipation
Decreased appetite
Diarrhea
Difficulty swallowing
Heartburn
Nausea
Vomiting
Ophthalmologic
Blurred vision
Diminished visual acuity
Endocrine
Cold when others are hot
Hot when others are cold
Respiratory
Cough
Coughing up blood
Pain with deep breathing
Shortness of breath at rest
Shortness of breath during
exercise
Breast
Nipple discharge
Breast lump
Breast pain
Hematology
Easy bruising
Prolonged bleeding
(Women only)
Irregular menses
Vaginal discharge
(Men only)
Hard testicle
Hernia
Penile discharge
Genitourinary
Blood in urine
Difficulty urinating
Painful urination
Musculoskeletal
Joint stiffness
Leg cramps
Muscle aches
Bone pain
Peripheral vascular
Cold hands or feet
Decreased sensation
Pain in hands or feet
Blisters or wounds
Skin
New mole or skin lesion
Neurologic
Balance difficulty
Difficulty speaking
Dizziness
Fainting
Loss of strength
Memory loss
Seizures
Acute loss of vision
Psychiatric
Anxiety
Depression
Southwest General Surgical Associates
General & Vascular Surgery
8230 Walnut Hill Lane Suite 408
Dallas, TX 75231
Phone-214)369-5432
Fax-214)369-5591
Andres U. Katz, M.D.
G. Thomas Shires III, M.D.
Robert M. Hagood, M.D.
Richard S. Anderson, M.D.
Ernest E. Beecherl, M.D.
James M. Sanders, M.D.
Attention:
It is the responsibility of the patient to verify with their insurance company that our physicians are participating
providers with their particular insurance plan. The provider is not always current and it is impossible for our
office to verify every patient’s insurance. This will keep the patient from possibly owing a large out of pocket
expense.
Referrals:
Patients whose insurance requires a referral are responsible to contact their primary care physician and have
them initiate it with your insurance provider. If the patient requires a referral and we have not received it by the
time of your visit, the patient will be responsible for the total charge of the visit at the time of service.
___________________________________
Signature of patient
__________________
Date
Southwest General Surgical Associates
Patient Consent Form
USE AND DISCLOSURE OF HEALTH INFORMATION FOR
TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
I understand that as part of my healthcare, Southwest General Surgical Associates originates and maintains
health records describing my health history, symptoms, examination and test results, diagnosis, treatment and
any plans for the future care or treatment. I understand that this information is utilized to plan my care and
treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine
healthcare operations such as assessing quality and reviewing competence of healthcare professionals.
Southwest General Surgical Associates ' NOTICE OF PRIVACY PRACTICES provides specific information
and complete description of how my personal health information may be used and disclosed. I have been
provided a copy of or access to NOTICE OF PRIVACY PRACTICES and understand that I have the right to
review the notice prior to signing this consent. I understand that Southwest General Surgical reserves the right
to change the NOTICE OF PRIVACY PRACTICES. Prior to implementation of the revised NOTICE OF
PRIVACY PRACTICES the revised NOTICE will be mailed to me if I provide my address below .I
understand I have the right to restrict the use and /or disclosure of my personal health information for treatment
, payment or healthcare operations and that Southwest General Surgical Associates is not required to agree to
the restrictions requested. I may revoke this consent at any time in writing except to the extent that Southwest
General Surgical Associates has already taken action in reliance on my prior consent. This consent is valid until
revoked by me in writing.
_____ I request the following restrictions on the use and/or disclosure of my personal
health information:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I further understand that any and all records, whether written, oral or in electronic format are confidential and
cannot be disclosed without my prior written authorization except as otherwise provided by law.
I have been provided and have reviewed Southwest General Surgical Associates
NOTICE OF PRIVACY PRACTICES dated January 4, 2002
________________________________________
Signature of Patient or Legal Representative, Date
_________________________
Witness, Date
________________________________________
Print Name of Patient or Legal Representative
__________________________
Print Name or Witness
Southwest General Surgical Associates, PA
Name:
SS#:
Home Phone:
Work Phone:
Cell Phone:
Address:
E-Mail:
City, State, Zip:
Sex: M / F Age:
Birth date:
Marital Status:
Patient Employer/School:
Occupation:
Who referred you to this office?
Phone:
Primary Care Physician:
Phone:
Preferred Pharmacy:
Name:
Address:
Phone:
Responsible Party Information
Relationship:
DOB:
Employer:
City, State, Zip:
Phone:
Name:
Home Phone:
SS#:
Emergency Contact Information
Relationship:
Work Phone:
Insurance Information (please provide your insurance card to the receptionist)
Carrier Name:
Policy Number:
Carrier Name:
Policy Number:
Cardholder Name:
Group #:
Secondary Insurance Information
Cardholder Name:
Group #:
Assignment and Release:
I certify that I, and/or my dependent has insurance coverage with
and assign directly to
Southwest General Surgical Associates, PA 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. Southwest General Surgical Associates, PA may use my health care information
and may disclose such information to the above named insurance companies 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.
Signed:
Date:
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
I hereby authorize the use or disclosure of information from the medical record of:
Patient Name:
Date of Birth:
Social Security#:
I authorize:
Phone Number:
Fax Number:
To disclose the above named individual’s health information. This information may be disclosed TO and used by the following individual or
organization:
Southwest General Surgical Associates
8230 Walnut Hill Lane, Suite 408
Dallas, TX 75231
Phone 214-369-5432 Fax 214-369-5591
For the purpose of:
Please release the following:
[ ] Problems List
[ ] Progress Notes
[ ] History/Physical Exam
[ ] Medication List
[ ] Immunization Records
[ ] List of Allergies
[ ] Other (specify)
[
[
[
[
[
[
] X-Ray / Imaging reports from (date)
] X-Ray Films
] Lab results from (date)
to
] EKG report
] Genetic Testing Information
] Other Diagnostic Reports
to
I understand that the information in my health record may include information relating to sexually transmitted disease, Acquired
Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health
services, and treatment for alcohol and drug abuse.
I understand that the information released is for the specific purpose stated above. Any other use of this information without the written
consent of the patient is prohibited.
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present my written revocation to the individual or organization releasing information. I understand that the revocation will not apply to
information already released in response to this authorization. I understand that the revocation will apply to my insurance company when the law
provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date,
event or condition:
. If I fail to specify an expiration date, event or condition, this
authorization will expire in 6 months.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this
form in order to ensure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I
understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected
by the federal confidentiality rules. If I have any questions about disclosure of my health information, I can contact Southwest General Surgical
Associates office manager.
Signature of patient or Legal Representative
Date
COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO THE PATIENT:
I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and have been
advised that I should contact my physician regarding entries made in my medical record to prevent my misunderstanding of the information
contained in these entries. I will not hold Southwest General Surgical Associates liable for any misinterpretation of the information in my medical
record as a result of not consulting my physician for the correct interpretation.
Signature of Patient or Legal Representative
Relationship to patient (if legal representative)
Date request complete
Cash
Check#
Date
# of pages copied
Initials:
Witness
Reviewed only
Charges$