Denise Ortega Sanderson, M.D.
Patient Information Sheet
Name: ________________________________________________________________________________________
(First)
(Middle)
(Last)
Address: ______________________________________________________________________________________
City: _______________________________ State: _______________________ ___Zip: _______________________
Race: ________________________ Ancestry: ______________________ Religion (optional) __________________
Language: ______________ __Social Security Number: _______________________Birthdate: _________________
Home Phone: ______________________ Cell Phone: ____________________ Marital Status: S
M
W
D
Work Phone: _________________________________ __ Email: __________________________________________
Emergency Contact: __________________________________ Phone: ____________________________________
Referring M.D._______________________________________Family M.D. ________________________________
Pharmacy Name: _________________________________ Address: ______________________________________
Phone Number: ____________________________________ Fax: ________________________________________
Do you give consent for our office to import your medications from your pharmacy if they are available?
Please Initial: ________ Yes ________No
Do you have any advanced directives? _____Living will _____DNR Power of Attorney: ______________________
Special Instructions explain if necessary:______________________________________________________________
Insurance Information:
Primary: _______________________________________Secondary: ______________________________________
Policy Holder (If other than self): ___________________________________________ SS#:____________________
D.O.B. ___________________ _________________ Relationship: ___________________ ____________________
I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO DR. DENISE SANDERSON. I REALIZE THAT I AM
RESPONSIBLE TO PAY NON-COVERED SERVICES (INCLUDING COLLECTION COSTS IN THE EVENT OF DEFAULT). A PHOTOCOPY OF
THIS AUTHORIZATION SHALL BE CONSIDERED AS VALID AS ORIGINAL. I FURTHER AUTHORIZE RELEASE OF MEDICAL
INFORMATION TO SECURE PAYMENT.
Patient Signature: ____________________________________________ Date: _____________________________
Denise Ortega Sanderson, M.D.
CONSENT AGREEMENT
By signing this form, you are granting consent to Dr. Denise Sanderson, M.D. to use and disclose your protected health
information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices
provides more detailed information about how we may use and disclose this protected health information. You have a
legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full.
You have a right to request us to amend your protected health information for the purposes of treatment, payment or
health care operations, in writing, explaining your reasoning for the amendment. We are not required by law to grant
your request. However, if we do decide to grant your request, we are bound by our agreement.
I understand and authorize, that at times it will be necessary for Dr. Sanderson and/or Staff to call my home or place of
business and leave messages on an answering machine, voice mail or e-mail.
You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your
protected health information in reliance on your request.
I fully understand and ACCEPT the terms of this consent.
____________________
I fully understand and DECLINE the terms of this consent.
____________________
Signature: _________________________________________________________________
Date: ______________________________________________________________________
Family and Friend Release of Information
I give permission to allow into the exam room, discuss my care with, and release information to the following listed
individuals.
NAME
RELATIONSHIP
_______________________________________________________
Patient’s Name Printed
_______________________________________________________
Signature/Date
PHONE NUMBER
REVIEW OF SYSTEMSBelow is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions
must be answered carefully as the problems may affect your overall course of care, as well as be signs of less than
optimal function.
Check those that you have experienced in the past and those that you are currently experiencing.
Constitutional
Heart & Circulation
Kidneys/Urinary Tract
____ Chills
____ Daytime drowsiness
____ Fatigue
____ Fever
____ Night sweats
____ Weight gain
____ Weight loss
____ Heart attack
____ High blood pressure
____ Heart murmur
____ Chest discomfort (angina)
____ Heart failure or fluid on the lungs
____ Palpitations, racing or pounding
____ Shortness of breath w/ activity
____ Stroke/mini stroke or TIA
____ Blood clot in artery or vein
____ “Black out spells”
____ Aneurysm of any blood vessel
____ Swelling of legs
____ Heart Surgery
____ Kidney disease or failure
____ History of kidney dialysis
____ Kidney stones or infection
____ Pain/burning with urination
_____ Trouble starting urinary stream
____ Dribbling or incontinence
____ Frequent Night Urination
____ Bladder infections during past yr
____ Blood in urine during past yr
Eyes
____ Wear glasses OR Contacts
____ Blindness
____ Cataracts
____ Glaucoma
Muscles/Bones/Joints
____ Arthritis or other joint disease
____ Chronic back trouble
____ Bone or joint surgery in past year
Ears/Nose/Throat
Stomach/Intestines
____ Difficulty/Loss of hearing
____ Ringing in the ears (tinnitus)
____ Frequent ear aches
____ Discharge from the ear
____ Attacks of vertigo
____ Sinus trouble
____ Nasal blockage
____ Frequent sneezing
____ Frequent sore throat
____ Snoring
____ Recent change in voice quality
____ Sleep apnea
____ Difficulty in swallowing
____ Nose bleeds
____ Ulcer
____ Frequent heartburn or indigestion
____ Hiatal hernia and or acid reflux
____ Poor appetite
____ Gall bladder attacks
____ frequent diarrhea
____ Chronic constipation
____ Bright blood bowels or rectum
____ Abnormal stool
____ Liver disease or jaundice
Nervous System
Endocrine/Metabolism
____ anxiety
____ loss or change in appetite
____ behavioral change
____ bi-polar disorder
____ confusion
____ convulsions
____ depression
____ insomnia
____ memory loss
____ mood change
Respiratory
____ Asthma or wheezing
____ Recent bronchitis or chest cold
____ Cough
____ coughing up blood
____ Shortness of breath
____ COPD
____ Thyroid disorder
____ Unusual hair loss or growth
____ goiter
____ Diabetes
Blood
____ Bleeding or bruising tendency
____ Previous blood transfusion
____ History of hepatitis
____ Migraines
____ Epilepsy or seizures
____ Date of last seizure: ___________
____ Other nervous disorder
Specify: _________________________
Psychologic
________________________________
Initial
________________________________
Date
Allergies
(Please list your drug allergies, include latex or adhesive allergies as well)
_____________________________________
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Social History
_____ Single
_____ Married
_____ Divorced
_____Separated
_____ Widowed
Work History
_____ Employed
_____ Unemployed
_____ Disabled
_____ Retired
_____ Self Employed
Habits
Tobacco
_____ Yes (How Much) ________________
_____ No ______Quit
Alcohol
_____ Yes (How Much) ________________
_____ No ______Quit
Caffeine
_____ Yes (How Much) ________________
_____ No ______Quit
Recreational Drugs
_____ Yes (How Much) ________________
_____ No ______Quit
Family History
(Please list family medical conditions)
Mother ____________________________________________________________________________________
Father
____________________________________________________________________________________
Sisters
____________________________________________________________________________________
Brothers ____________________________________________________________________________________
Other
_____________________________________________________________________________________
Gynecological History
Age you started period __________ Are you still having periods? __________ Your last Period: _________________
If yes, are they regular: ____________ If no, how old were you when they stopped? _________________________
Why did they stop? Menopause: _____________ Hysterectomy: ______________ Ablation: __________________
Number of pregnancies: __________ Number of live births: __________ Did you breast feed: _________________
How old were you when you had your first pregnancy? _________________________________________________
Contraceptives (Yes/No, What type? How long?) _______________________________________________________
Hormone Replacement Therapy (Yes/No, What type? How long?) _________________________________________
Breast History
Why are you here today?
___I feel something in my breast
___Abnormal Mammogram or Ultrasound
___Skin changes on breast
___My doctor feels something in my breast
___Breast Pain
___Other
Have you ever had a biopsy?
___ yes
___ No
If so what were the results?
___ Malignant (Cancer)
___ Benign (It was NOT cancer)
Which Breast?
___ Right
___ Left
Have you ever had breast surgery?
___ yes
___ No
What Type? ___________________________________________________________________________
Medical History
Surgical History
(Please list all medical conditions past and present and any prior surgeries)
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Medications and Dose
(Including vitamins & supplements)
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