Today’s Date: _______________
Name_________________________________ Date of Birth ________________________
? _______________
? (Circle)
Yes No if yes, what did you have ___________________ where? _______________
? _______________
Where is it located?
(Upper, Mid, Lower, Waistline, Shoulder, Hips) _______________________________
? (Circle)
Yes No If yes, please explain _______________________________________________
__________________________________________________________________________________
Circle all that apply to your pain:
Sharp Dull Burning Aching Numb Hot
Constant Intermittent tingling down leg(s) R or L Weakness
? Yes No If Yes, When? _________________
? (Circle any that apply)
New leg or arm weakness Loss of bladder or bowel control
Please describe____________________________________________________________________
Circle all that apply:
Ice Heat Rest Back Brace Surgery Steroid injection
Pain medicine Physical Therapy Chiropractor Exercise
? (Circle) Yes No
? (Circle) Yes No If yes, please Describe:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Past Medical History:
Please Circle all that apply: Diabetes- Oral medication Insulin Thyroid Disease Asthma HIV
Liver Disease Heart Disease- Type? ________________ Arthritis Osteoporosis Lung Disease
High Blood Pressure Heart Murmur Peptic Ulcer Cancer Bleeding Disorder Kidney Disease
High Cholesterol Depression Stroke Seizures Vascular Disease
Surgical History or Serious illness:
Type_______________________ Year_________________ Type _______________________Year______________________
Type_______________________ Year __________________Type_______________________ Year_____________________
Allergies:
Are you allergic to any medication, latex, surgical tape or dye? (Circle) Yes No
Please list________________________________________________________________________________________________
Please list any Prescription Medications, Herbal Products or over the counter medications you take OR bring a complete list with you.
Name_______________________________ Dose________________________ How many per day________________
Name_______________________________ Dose________________________ How many per day________________
Name_______________________________ Dose________________________ How many per day________________
Name_______________________________ Dose________________________ How many per day________________
Do You Take Blood thinning Medication? (Coumadin, Warfarin, Plavix, Asprin) (Circle) Yes No
If yes, what do you take, what strength and how often? _____________________________________________
Social History:
What is your occupation? ______________________________________________________________________________
What is your marital status? (Circle) Married Divorced Widowed Single
Do you currently smoke? (Circle) Yes No Never If Yes, How Much? __________ per day.
If No, What year did you quit? _______________ How many years did you smoke? ____________________
Do you Drink Alcohol? (Circle) Yes No If Yes, How many per week? ___________________
Family History:
Circle any condition on either side of your family
Allergies Heart Disease Kidney Disease Arthritis Bone Disease Blood Disease
Cancer Diabetes Thyroid disease Mental illness Bleeding Tendencies Other-
Please explain: ___________________________________________________________________________________________
____________________________________________________________________________________________________________

Circle all that apply to you.
General Eyes ENT Respiratory
Weight Loss Pain Sore Throat Wheezing
Weight Gain Discharge Hoarseness Cough
Fever Light Sensitivity Ears Ringing Shortness of Breath
Fatigue Blurred Vision Nose Bleeds
Cardiovascular Gastrointestinal Genitourinary Neurological
Chest Pain Nausea Hesitancy Confusion
Feet Swelling Vomiting Flank Pain Numbness
Palpitations Diarrhea Painful Urination Slurred Speech
Blood in Stool Blood in Urine Seizures
Musculoskeletal Skin/Breast Endocrine Hematology/Lymphatic
Joint Swelling Rash Excess Sweat Bleeding Tendencies
Joint Redness Itching Excess Thirst Lymph Node Swelling
Joint Pain Sores Excess Hot Easy Bruising
Gait Problems Abscess Excess Cold
Leg Pain with Walking Discharge
Psychological Explanations or Other: ___________________________________
Anxiety ___________________________________________________________________
Depression ___________________________________________________________________
Severe Stress ___________________________________________________________________
Panic Disorder ___________________________________________________________________
Claustrophobia ___________________________________________________________________
Patient/ Guardian Signature__________________________________________ Date ________________
Reviewed by: _________________________________________________________ Date ________________

PATIENT NAME:
YOUR FINANCIAL RESPONSIBILITY
Date of Birth:
Your insurance claims will be filed by Irvington Radiologists. Insurance claims are filed as a courtesy to our patients and as required by any contractual obligations that exist with the insurance programs that we participate in. We request all patients to submit a copy of their insurance card at each visit.
Be aware that should you have requirements placed on your insurance coverage by your insurance carrier such as pre-certification, co-payments, or non-covered charges, it will be necessary for you to fulfill these obligations. It is the responsibility of the patient to know his/her own insurance provisions. If you are unsure, please contact your insurance company or Human Resources department through your employer.
While the staff at Irvington Radiologists is happy to contact your carrier and ask for verification or preauthorization of coverage, this is only a report to us of the potential for reimbursement; it is not a guarantee of payment or coverage. We do not promise or guarantee any insurance coverage or benefits. Again, please read your insurance company’s handbook or refer to your own carrier for such guarantees.
Should you wish to ask financial questions or make payment arrangements, please contact our Billing
Office at 317-579-2131 Monday through Friday 7:00 am to 3:30 pm. We will be happy to answer any of your questions.
By signing this form you are acknowledging that you have read it, agreed and understand that regardless of the action(s) of your insurance company/employer, the financial responsibility for services rendered is ultimately your responsibility.
RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received the Irvington Radiologists, PC, Notice of Privacy Practices.
IRV Use Only: If the patient did not sign or initial, give reason & initial:
Initial as an acknowledgement of receipt on file:
RELEASE OF INFORMATION:
I hereby assign all medical and/or surgical benefits, including private insurance and other plans due me to be made directly to Irvington Radiologists, PC. I authorize disclosure of portions of the patient record to the extent necessary to determine liability for payment and to obtain reimbursement, as well as disclosure to other physicians as needed for consulting. I hereby appoint Irvington Radiologist’s employees as my representative to file grievances and appeals for me with my insurance company. This is in accordance with
Indiana code, title 27, chapters 8 and 13.
I give the staff of Irvington Radiologists permission to release results to me or a designated person(s)
(indicated below). This waiver remains in effect as long as I am a patient at Irvington Radiologists or until otherwise revoked in writing.
Name: __________________________________________ Date of Birth: ________________________
Name: __________________________________________ Date of Birth: ________________________

Yes

No
X:
Date: