West Georgia Center for Diabetes & Endocrinology
PATIENT INFORMATION:
Full Name:
DOB:
ADDRESS:
Gender:
Male:
Female:
SS Number:
City:
Check primary contact
phone:
Home Phone:
State:
Cell Phone:
E: Mail Address:
Zip code:
Work Phone:
E-mail notification for web portal update:
Yes:___________ No:____________
Marital Status:
Married:
Race:
Single:
Asian:
Black:
Ethnicity:
Hispanic:
Divorced:
Separated:
Hawaiian/Pacific Islander:
Non -Hispanic:
Primary Care Provider:
Widowed:
Native American:
Life Partner:
White:
Mixed:
Occupation:
Referring Provider:
EMERGENCY CONTACT:
Spouse/Authorized person
Name:
Contact phone:
INSURANCE INFORMATION:
Primary:
Group#
Policy #
Policy Holder Name:
Birthday:
Address:
Secondary:
Group#
Policy #
Pharmacy:
Preferred:
Secondary:
I hereby authorize and consent for Medical services and authorize to release information
required for processing insurance claims and benefits paid directly to the Practice.
_____________________________________
Patient’s signature
Form effective date: 1/7/2015
_______________________
Date
West Georgia Center for Diabetes & Endocrinology
REVIEW OF SYSTEMS
Patient’s Name:______________________________
N
Y
DOB:_________________
N
Y
N
GENERAL
Shortness of breath
BREAST
Recent weight gain
Wheezing
Nipple discharge
Recent weight loss
Asthma
Fever
Fatigue
GASTROINTESTINAL
Loss of appetite
NEUROLOGICAL
Headaches
Sweat
Heat intolerance
Cold intolerance
Constipation
Nausea
Vomiting
Seizures
Stroke
Memory loss
EYES & VISION
Eye disease/injury
Cataract
Glaucoma
Diarrhea
PSYCHIATRIC
Nervousness
Depression
Loss of concentration
Blurred vision
Double vision
Last Eye exam date:
__________
EAR,NOSE,THROAT
Hearing loss
Abdominal pain
Blood in stool
GENITOURINARY
Waking up at night to
urinate
Frequent urination
Burning urination
Dizziness
Sleep problems
HEMATOLOGIC
Cuts slow to heal
Bruise easily
Anemic
Ringing in ear
Blood in urine
Incontinence/urine
leakage
Sexual dysfunction
Ear pain or discharge
Sinus problems
Nose bleeds
MUSCULOSKELETAL
Joint pain
Joint stiffness/swelling
Recurring infections
CARDIOVASCULAR
Chest pain
Difficulty walking
Muscle pain
Hives
History of HIV/Aids
Shortness of breath
Weakness of muscle
Heart racing
Broken bones
ENDOCRINE
Excessive thirst
Sudden loss of
consciousness
Swelling of
feet/ankles/hand
RESPIRATORY
Chronic cough
INTEGUMENTARY
Coughing blood
Thin brittle nails
Form effective date: 1/7/2015
Rashes/itches
New moles/lesions
Sudden hair loss
Swollen Lymph nodes
IMMUNOLOGIC
Hay fever
Unexpected change
in skin color
Heat/cold intolerance
Dry skin
Y
West Georgia Center for Diabetes & Endocrinology
Patient’s Name:__________________________________
DOB:__________________________
Past Medical History: Please mark if you have been treated to any of the following illnesses.
Asthma
Anemia
Adrenal Disease
Cancer Type:_______________
COPD
Depression/Anxiety
Heart attack
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Liver disease
Pituitary disease
Seizures
Sexual problems
Stroke
Thyroid disease
Ulcers
Diabetes
Please list past surgeries:
Osteoporosis
Vision problems
Allergies & Reactions: Please list ALL allergies (Include adverse reactions to any medications)
SOCIAL HISTORY:
Tobacco use: Current:__ Past:___(When did you quit:______)
Type: Cigarettes/cigars/Chewing
How many/ day_____ How many years:_____
Alcohol Use:
Never: ________ Rarely: ______ Daily:_________ number of drinks/week____________
Recreational Drug Use: No:_____ Yes:______ Type & How much?_____________________________
Caffeine use (Coffee, Tea, soft drinks: No: _____ Yes:_______ How many/day?____________________
Exercise: Do you exercise regularly? ___________ What type & how often?________________________
Are you on a diet? No:________ Yes:_________ How long?____________________________________
FAMILY HISTORY: Mark the blood relatives who had the following diseases:
DISEASE
Cancer
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Pituitary Disease
Thyroid Disease
Stroke
Form effective date: 1/7/2015
Mother
Father
Brother (s)
Sister(s)
West Georgia Center for Diabetes & Endocrinology
Thank you for choosing us as your healthcare provider. A clear understanding of our policies will help us to
build a successful relationship.
INSURANCE:
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We participate with several insurance plans. Please verify your insurance information with the office
prior to making the appointment.
You should be familiar with your insurer’s requirements such as referrals, pre approvals, deductions, copays and the medications covered by your insurance.
We will verify your insurance status at each visit. You are responsible to let us know if your insurance
plans have changed.
As a courtesy, we will directly bill your primary and secondary insurance providers. You are responsible
for all payments that are not covered.
PAYMENT:
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Payment is expected at the time of service. Payment includes deductibles, co-insurance, co-pays and
non- covered charges.
Self- pay patients must pay in full or most of the charges at the time of the service.
We accept cash, check or credit card ( Visa and Master charge)
Payments are expected within the due date specified in the monthly statements.
ADDITIONAL CHARGES AND INFORMATION:
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Returned checks will incur a $25 fee
We require a 24 hour notice for appointment cancellation. A $25 fee will be applied for missed
appointments without notification.
There is a fee for copying Medical records. A fee up to $25 may be charged based on the number of
pages. A summary of care is provided after each visit free of charge.
Access to electronic medical records is available through secure connection.
All delinquent accounts will be sent to a collection agency. You will be responsible for the collection
agency fess.
Medication refill requests should be completed at the time of the office visit. If a refill is required, please
request it through the pharmacy and it will be provided with in 24-48 hours. There is no charge for this
service. Please note that if the patient has not been seen by the Provider recently, we do not issue refills.
APPROVAL: I have read the above payment and attached privacy policies and agree to them.
Patient’s signature
Form effective date: 1/7/2015
Date