THE GYNECOLOGIC ONCOLOGY CENTER
NAME:
HOW WOULD YOU LIKE TO BE ADDRESSED: Choose an item.
SOCIAL SECURITY NUMBER:
DATE: Click here to enter a date.
DATE OF BIRTH:
ADDRESS:
CITY:
STATE:
TELEPHONE: HOME
EMAIL:
ZIP:
CELL
Married
Single
WORK
Widowed
Divorced
LAST MENSTRUAL PERIOD: Click here to enter a date. PRIOR MENSTRUAL PERIOD: Click here to enter a
date.
METHOD OF BIRTH CONTROL:
CURRENT MEDICAL ISSUES:
MEDICAL/SOCIAL CHANGES – SINCE LAST EXAM:
CURRENT MEDICATIONS:
PHARMACY NAME AND LOCATION:
PACEMAKER: Choose an item.
DRUG ALLERGIES:
DATE AND LOCATION OF LAST MAMMOGRAM:
DATE AND LOCATION OF LAST COLONOSCOPY:
DATE AND LOCATION OF LAST DEXA SCAN:
PHYSICIANS WHO ARE TO RECEIVE REPORTS OF THIS VISIT: NAME & ADDRESS:
PLEASE CALL (410) 332-9210 FOR RESULTS OF ANY TEST DONE IN CONJUNCTION WITH THIS
VISIT – NO RESPONSE DOES NOT NECESSARILY MEAN YOUR RESULT WAS NORMAL
PLEASE SIGN TO ACKNOWLEDGE THAT YOU HAVE READ THE ABOVE. (BY TYPING YOUR NAME
YOU AGREE THAT YOUR TYPED NAME SERVES AS YOUR SIGNATURE)
SIGNATURE
DATE Click here to enter a date.
FOR OFFICE USE ONLY
TESTS: PAP ______ ECC ______ CX. BX ________ ENDO BX_______
URINALYSIS ______ URINE C & S ______
CX CULTURES _________
F/U APPT ____________________ TEST ORDERED________________
HEIGHT: ____________
WEIGHT: P_____/C____
BMI: ________________
BP:_________________
PO TEMP: ___________
NOTES
Medical Assistant Signature_________________________
HEALTH REVIEW
(Review of Symptoms)
Check all symptoms that apply to your health status:
General
Head
Eyes
fatigue
headache
blurred vision
fever
dizziness
double vision
Ears
hearing loss
ringing in ears
Nose & Throat
nose bleeds
hoarseness
nasal congestion
runny nose
cough
wheezing
blood in sputum
yellow or green sputum
Heart
chest discomfort
palpitations
ankle swelling
Gastrointestinal
trouble swallowing
nausea
vomiting
Respiratory
night sweats
spots
sneezing
short of breath
heart burn
indigestion
abdominal pain
change in bowel movements/habits
diarrhea
rectal bleeding
black bowel movements
pleurisy
heart attack
constipation
leakage of stool: how often
Urinary
Musculoskeletal
Can you hold gas:
Yes
No
Change in size of stool:
Smaller
Larger
blood in urine
urgency
painful urination
incontinence
decrease in stream
back pain
muscle pain
frequent urination
wake up at night to urinate
joint pain
How many times?
joint swelling
stiffness
Neurological
seizures
stroke
loss of balance
numbness
difficulty with speech
Hematologic
bleeding
bruising
Skin
rash
itching
Psychiatric
depression
anxiety
trouble walking
difficulty sleeping
Pain Index
Please choose the face that best describes your current pain level
0
2
4
6
8
10
For Physicians assessment only **** Please do not write below this line
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Depression Assessment
1. During the past month, have you
often been bothered by feeling
down, depressed, or hopeless?
Yes
2. During the past month, have you
often been bothered by having little
interest of pleasure in doing things?
No
Yes
3. Have you or are you in a
relationship where you have been
threatened, abused, or feel trapped?
No
Yes
No
If you have answered “yes” to any of the above, please proceed to answer the following questions:
Yes
No
I am sad, blue, or down for most of the day, almost every day?
I don’t enjoy my usual activities and hobbies as much as I used to?
My appetite and my weight have changed significantly in recent months and I have not been dieting?
I find myself sleeping much more (or much less) than normal?
I am agitated and keep moving around?
It takes a great effort for me to do simple things?
I feel like a failure or that I am a guilty person who deserves to be punished?
I have trouble concentrating or making decisions?
I have spent time thinking about death or suicide?
Wellness Index:
Please choose the face that best describes your level of well being.
0
2
4
6
8
10
Distress Management
SCREENING TOOLS FOR MEASURING DISTRESS
Instructions: First, please choose or
Second, please indicate if any of the following has been a problem for
circle the number (0-10) that best
you in the past week including today. Be sure to check YES or NO for
describes how much distress you
each.
have been experiencing in the past
Practical Problems
Yes No Physical Problems
Yes No
week including today.
Child Care
Appearance
Housing
Bathing/Dressing
Insurance/financial
Breathing
Transportation
Changes in Urination
Work/School
Constipation
Diarrhea
Family Problems
Eating
Dealing with children
Fatigue
Dealing with partner
Feeling Swollen
Fevers
Getting Around
Indigestion
Memory/concentration
Mouth Sores
Nausea
Nose dry/congestion
Pain
Sexual
Skin dry/itchy
Sleep
Tingling in hands/feet
Emotional Problems
Depression
Fears
Sadness
Nervousness
Worry
Loss of interest in usual
Activities
Spiritual/religious concerns
Other Problems:
The following medical issues were reviewed with this patient:
Depression Assessment
Distress Management Tool
Review of Medical Symptoms
Pain Assessment
Family History
Medical Concerns
Medications
Physician ____________________________________________________________Date________________________________________
CONSENT AND ASSIGNMENTS
MEDICARE
I authorize any holder of medical or other information about me to release to the Social Security Administration &
Centers for Medicare & Medicaid Services (CMS) or its intermediaries or carries any information needed for this or a
related Medicare claim (Title XVIII). I permit a copy of this authorization to be used in place of the original and request
payment of medical insurance benefits to the party who accepts assignment.
BLUE CROSS/BLUE SHIELD OF MARYLAND
Dr. Neil B. Rosenshein, Dr. Dwight D. Im and Dr. Hyung S. Ryu are participating physicians of Blue Cross/Blue
Shield of Maryland, Inc. I authorize release of any medical information necessary to process this claim. I understand that I
am responsible for any deductible and co-payment.
INSURANCE ASSIGNMENT
I authorize and assign payment directly to the physicians involved in my treatment and authorize release of medical
information necessary to process the claim. I further understand I am financially responsible for charges not covered by
my insurance.
MANAGED CARE
I understand that without an authorization/referral form from my HMO/IPA/PPO I will be financially responsible for
charges I incur.
***IMPORTANT INSURANCE INFORMATION***
Many insurance companies will no pay for routine gynecologic examinations once a year.
Routine gynecologic examinations will be billed as preventative healthcare. If you insurance company does not pay for
routine and/or preventative health visits, you are expected to pay for services at the time of visit.
If there are any special instructions for billing your insurance company for your office visit and/or laboratory work, please
inform our office staff at the time of the visit. Once the bill has been submitted to your insurance company, we cannot
make any changes to procedures or diagnostic codes.
Ultimately, you are responsible for payment to our physicians for services rendered. Your signature below acknowledges
your understanding and your agreement to fulfill all financial obligations.
BILLING NOTICE TO OUR PATIENTS
The Gynecologic Oncology Center is an outpatient department of the hospital. Accordingly, you may receive two bills for
your appointments in the Center. You may receive a physician services bill from the physician group and an outpatient
clinic bill from the hospital. Together, the two bills represent charges incurred during your visit to the Center and we
provide this notice to help avoid confusion if you receive to separate bills.
Depending on your insurance coverage, you may be responsible for some or all of both bills. All charges are billed to the
patient’s insurance company to determine the co-pay, deductible, and/or coinsurance amounts.
Thank you.
I have read and understand this billing notice:
Patient name – printed
Patient Date of Birth
Patient Signature (by typing my name this serves as my signature)
Date of Signature