Asheville Internal Medicine
Patient Name: __________________________________________ Sex: __ Age: ____ Date of birth: ____________
Address: ______________________________________________________________________________________
Phone (H): (___)__________________ (W) (___)_____________ Social Security #: _________________________
Race:
Caucasian
Marital Status:
Work Status:
Student Status:
African American
Single
Full time
Married
Part time
Full time
Part time
Asian
Hispanic
American Indian
Legally Separated
Divorced
Not Employed
Self Employed
Other
Widowed
Retired
Active Duty
Not Student
Patient’s Employer & Address: ____________________________________________________________________
Spouse’s Employer & Address: ____________________________________________________________________
Emergency Contact (Name, Address, Phone Number): _________________________________________________
_________________________________________________ Relationship to patient: _______________________
If you are ill and cannot take care of yourself, who will help you? _________________________________________
Who referred you to this office? ___________________________________________________________________
All professional services rendered are charged to the patient. We request that you pay for services when rendered unless other arrangements
are made in advance. You will be given a copy of your encounter form which contains all information needed to file with your insurance
company. The Patient is Responsible For All Charges, Regardless of Insurance Coverage.
Medicare ID #____________________________ Policy Holder Name _____________________________________
Other Insurance Company _________________________________ ID # ___________________________________
Policy Holder Name __________________________________________ Group # ___________________________
Address Where Claim to be mailed _________________________________________________________________
Other Ins Company ___________________________________________ ID # ______________________________
Policy Holder Name _______________________________________________ Group # ______________________
Address where claim to be mailed _________________________________________________________________
AUTHORIZATION TO RELEASE INFORMATION: I give my authorization for my medical records to be sent to other doctors I may be seeing. I
authorize the use of photostatic copy of this agreement and authorization in lieu of original when necessary.
___________________________________________________
Signature of Patient or Responsible Party
________________________________________
Date
AUTHORIZATION FOR PAYMENT: I authorize the release of my medical information necessary to process the claim and request payment of
Medicare benefits to the party who accepts assignment. I understand that I am responsible for all charges, regardless of insurance coverage.
___________________________________________________
Signature of Patient or Responsible Party
_________________________________________________
Date
Social/Cultural History:
Do you have any children? ________ If so, how many? ________
Are there any specific personal problems or concerns you would like to discuss? ____________________________
Are there any cultural or religious concerns that you have related to our delivery of care? ____________________
Are there any specific household problems that you would like to discuss? _________________________________
Are there any financial issues that you would like to discuss? ____________________________________________
Have you had any occupational changes?
Disabled
Unemployed
Other__________________________
Have you experienced a recent death of a family member?
Spouse
Parent
Sibling
Child
Other
Any other social issues that you would like to discuss? _________________________________________________
Communication:
Language of preference: _________________
Any vision problems that affect your communication. Y N. If yes, please describe________________________
Any Hearing Problems: Y N. If yes, please describe: ___________________________________________
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: (Including exact dosage & frequency)
Name
Dosage
How often
Name
Dosage
How often
1.___________________________________________
2. _________________________________________
3. ___________________________________________
4. _________________________________________
5. ___________________________________________
6. _________________________________________
7. ____________________________________________
8. _________________________________________
9. ____________________________________________
10. _________________________________________
LIST ALLERGIES TO MEDICINES: ___________________________________________________________________
ARE YOU ALLERGIC TO LATEX, IODINE, OR X-RAY DYE? (PLEASE CIRCLE) Y N
Personal Medical History: Do you or have you ever had any of the following? Please explain
Eye Problems ____________________________
Ulcer/Colitis/Bowel ________________________
Thyroid Disease ___________________________
Diabetes _________________________________
High Cholesterol __________________________
Neurological Disease _____________________
Blood Disease (Anemia/Leukemia) ______________
Skin Disease _____________________________
Depression/Anxiety _______________________
Abuse __________________________________
Illegal Prescription Drug Abuse ______________
GYN Problems (for women only) ____________
Kidney/Bladder Problems ________________________
Ear Problems ___________________________________
Sinus Problems _________________________________
Respiratory Disease (Pneumonia, Bronchitis, etc) ___________
High Blood Pressure _____________________________
Heart Disease (Heart attack, chest pain, ect) _______________
Stroke/ TIA ____________________________________
Circulatory Disease ______________________________
Bone/Joint Disease _____________________________
Alcohol Abuse __________________________________
Other mental health disorders _____________________
Prostate Problems (for men only) __________________
Please list past surgeries, hospitalizations or injuries:
Operations/Illness
Date
Physician/Hospital
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Family Medical History: (Please check if grandparent, parent, sibling or child has a history with these health issues)
Heart Disease _______________
High Cholesterol ________________
Glaucoma _________________
High BP ____________________
Lung Disease ___________________
Kidney Disease _____________
Stroke/TIA __________________
Asthma ________________________
Breast Cancer _____________
Diabetes ___________________
Anemia/Blood __________________
Cancer ____________________
Thyroid ____________________
Alzheimer’s Disease ______________
Depression/Anxiety _________
Alcohol Abuse _______________
Drug Abuse _____________________
Other mental health disorder _____________
Any other family medical issues _______________________
Tobacco History:
Do you currently use tobacco products?
Yes
No
If yes, please indicate the type of tobacco products below:
Cigarettes
Pipe
Cigars
Smokeless
Other tobacco products
(orbs, strips, sticks, hookah, etc)
Packs per day (20 cigarettes/pack): _________________________________________
Bowls per day: _________________________________________________________________
Number per day: _____________________________________________________________
Cans/pouches per day: ______________________________________________________
Amount per day: _____________________________________________________________
Medication used in previous quit attempt:
No medication
Nicotine patch
Nicotine gum
Nicotine lozenge
Nicotine nasal spray
Nicotine oral inhaler
Varenicline
Bupropion
Other: ______________________________________________
Readiness to Quit:
Not interested in quitting
Would like to quit sometime (but not within the next month)
Would like to quit now or soon (within the next month)
Other smokers in household?
Yes
No
Fall Risk Assessment:
Have you had any falls in the past year?
Yes
No
Do you have any worries about falling or feel unsteady when standing or walking?
Yes
No
If so, please explain ___________________________________________________________________________________________________
Assessment of Risky Health Behaviors:
Do you drink alcohol?
Y
N # of drinks at a time ______ How many days per week? ____________________
When was the last time you had more than 4-5 drinks in one day? never in past 3 months
over 3 months
How often do you exercise?
never
rarely 1 to 3 times/month
1 to 3 times/ week
4 to 6
times/week
7 days/week
Are you sexually active?
Y N Do you have any sexual concerns?
Y
N Have you ever been treated for a
sexually transmitted disease?
Y
N
Do you have any reason to suspect that you have been exposed to HIV or AIDS?
Y
N
Do you handle and control the stress in your life?
Y
N
Do you sleep well at night?
Y N How many hours? _______
Have you experienced a serious life event recently (death, divorce, new job, moved, etc?)
Y
N
If yes, please explain ____________________________________________________________________________
Depression Assessment
In the past month:
Have you often been bothered by feeling down, depressed or hopeless?
Y
N
Have you often been bothered by little interest or pleasure in doing things?
Y
N
Are you generally happy with your life and your current health?
Y
N
When was your last exam? (Indicate Year and Results)
EKG: _____________________________________
Physical Exam: _____________________________
Chest X-ray: _______________________________
Pneumonia Vaccine: ________________________
Tetanus Vaccine: __________ Td or
Tdap
Zostavax: _________________________________
Colonoscopy: _______________________________
Mammogram: _______________________________
Pap Smear: _________________________________
Bone Density: _______________________________
Flu Vaccine: _________________________________
Dental Exam: ________________________________
Advance Care Planning:
Do you current have any of the following?
Living Will; Five Wishes;
DNR;
MOST;
Health Care Power of Attorney;
Other _______________
Review of Systems:
Constitutional
Good General Health
Recent Weight Changes
Night Sweats/ Fever
Fatigue/Weakness
Sleep Problems
YN
YN
YN
YN
YN
Cardiovascular
Chest pain
Palpitations
Heart Trouble
Swelling Hands/Feet
YN
YN
YN
YN
ENT
Hearing loss or ringing
Sinus Problems
Nose Bleeds
Sore Throat
YN
YN
YN
YN
EYES
Wear glasses/contacts
Blurred/double vision
Eye disease or injury
Glaucoma
YN
YN
YN
YN
Respiratory
Shortness of breath
Cough
Wheezing/Asthma
Coughing up blood
YN
YN
YN
YN
Musculoskeletal
Muscle pain or cramps
Stiffness/swelling joints
Joint Pain
Trouble walking
YN
YN
YN
YN
Neurological
Frequent headache
Paralysis or tremors
Convulsions/seizures
Numbness/tingling
YN
YN
YN
YN
Hematologic/Lymphatic
Bruise easily
YN
Enlarged glands
YN
Gastrointestinal
Nausea/vomiting
Abdominal pain
Constipation
Diarrhea
Rectal bleeding
Integumentary (Skin/Breast)
Change in hair or nails
YN
Rashes or itching
YN
Breast Lump
YN
Breast pain/discharge
YN
Endocrine
Excessive thirst
Thyroid disease
YN
YN
Psychiatric
Insomnia
Confusion/Memory loss
Depression
Genitourinary
Blood in urine
Kidney stones
Testicle pain
Abnormal periods
YN
YN
YN
YN
YN
YN
YN
YN
YN
YN
YN
YN
__________________________________________
Patient Signature
____________________________
Date
__________________________________________
Patient Printed Name
___________________________________________
Physician Signature
_____________________________
Date