New Patient Application Step 1 of 8 - Page ! 0% Adult Confidential Health QuestionnaireFirst Name* First Last Name* Last Date Of Birth Date Format: MM slash DD slash YYYY Your answers on this form will help your clinician understand your medical concerns and conditions. If any question makes you uncomfortable or is not applicable, feel free to leave it blank. Best estimates are fine if you cannot remember specific details. If you have any questions or concerns, don’t hesitate to ask us. Please complete all 5 PAGES. Thank you! PERSONAL INFORMATIONPreferred Name (if different from above):What language would you prefer to use with us?Will you need an Interpreter?YesNoEmail Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone:Alternate Phone:What is the best way for our office to contact you? Phone Patient Portal/Email (FollowMyHealth) Please sign up for our patient portal, FollowMyHealth. We encourage the use of FollowMyHealth as a preferred means of communication. Sign Me Up Primary CaregiverCaregiver N/A I have no primary caregiver/not applicable NameRelationshipPrimary Phone NumberAlternate Phone NumberLegal Guardian I have no primary legal guardian/not applicable NameRelationshipPrimary Phone NumberAlternate Phone NumberPRESENT HEALTH CONCERNS:Do you have any Health Care Goals you’d like to discuss today?In general, would you say your health is:ExcellentVery GoodGoodFairPoorPREFERRED PHARMACY:Name:Location:MEDICATIONSPrescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbsMedicationDoses & Time/Day ALLERGIESAllergies or reactions to medicines, foods, other agents:Allergies (Medical, Environmental)Reaction or Side Effect Untitled I take no regular medications. I have more than 5 and will bring a complete list of medications with all samples/containers I have. I have no known allergies IMMUNIZATIONSPlease check your most recent immunizations. Hepatitis A Hepatitis B HPV Tetanus (Td) Meningitis Measles Mumps Rubella MMR Pneumovax (Pneumonia) Varicella (Chickenpox) Shingles Other Hepatitis APlease include your best estimate of the month and year of each immunization:Hepatitis BPlease include your best estimate of the month and year of each immunization:HPVPlease include your best estimate of the month and year of each immunization:Tetanus (Td)Please include your best estimate of the month and year of each immunization:MeningitisPlease include your best estimate of the month and year of each immunization:MeaslesPlease include your best estimate of the month and year of each immunization:MumpsPlease include your best estimate of the month and year of each immunization:RubellaPlease include your best estimate of the month and year of each immunization:MMRPlease include your best estimate of the month and year of each immunization:Pneumovax (Pneumonia)Please include your best estimate of the month and year of each immunization:Varicella (Chickenpox)Please include your best estimate of the month and year of each immunization:ShinglesPlease include your best estimate of the month and year of each immunization:OtherSELF / FAMILY MEDICAL HISTORYFather's Age:Cause:Mother's Age:Cause:Please indicate if you or any family members have had any of the following conditions: I do not know my family history Alcoholism Self Mother Father Sister Brother Daughter Son Other Glaucoma Self Mother Father Sister Brother Daughter Son Other Anemia Self Mother Father Sister Brother Daughter Son Other Hay fever (Allergies) Self Mother Father Sister Brother Daughter Son Other Allergies (environmental) Self Mother Father Sister Brother Daughter Son Other Hearing Problems Self Mother Father Sister Brother Daughter Son Other Anesthesia Problem Self Mother Father Sister Brother Daughter Son Other Heart Attack (CAD) Self Mother Father Sister Brother Daughter Son Other Anxiety/Depression Self Mother Father Sister Brother Daughter Son Other Heart Valve Problems Self Mother Father Sister Brother Daughter Son Other Arthritis Self Mother Father Sister Brother Daughter Son Other High Blood Pressure Self Mother Father Sister Brother Daughter Son Other Asthma Self Mother Father Sister Brother Daughter Son Other High Cholesterol Self Mother Father Sister Brother Daughter Son Other Atrial Fibrillation Self Mother Father Sister Brother Daughter Son Other Kidney Diseases Self Mother Father Sister Brother Daughter Son Other Birth Defects Self Mother Father Sister Brother Daughter Son Other Lupus (SLE) Self Mother Father Sister Brother Daughter Son Other Blood Transfusion Self Mother Father Sister Brother Daughter Son Other Developmental Delay Self Mother Father Sister Brother Daughter Son Other Cancer, Breast Self Mother Father Sister Brother Daughter Son Other Migraine Self Mother Father Sister Brother Daughter Son Other Cancer, Colon Self Mother Father Sister Brother Daughter Son Other Obesity Self Mother Father Sister Brother Daughter Son Other Cancer, Melanoma Self Mother Father Sister Brother Daughter Son Other Osteoarthritis Self Mother Father Sister Brother Daughter Son Other Cancer, Ovary Self Mother Father Sister Brother Daughter Son Other Osteoporosis Self Mother Father Sister Brother Daughter Son Other Cancer, Prostate Self Mother Father Sister Brother Daughter Son Other Polycystic Ovaries Self Mother Father Sister Brother Daughter Son Other Cancer, Thyroid Self Mother Father Sister Brother Daughter Son Other Psychiatric Hospitalizations Self Mother Father Sister Brother Daughter Son Other Cancer, other known site Self Mother Father Sister Brother Daughter Son Other Pulmonary Embolism Self Mother Father Sister Brother Daughter Son Other Coagulation (bleeding/clotting problem) Self Mother Father Sister Brother Daughter Son Other Rheumatoid Arthritis Self Mother Father Sister Brother Daughter Son Other Colon Polyps Self Mother Father Sister Brother Daughter Son Other Seizures Self Mother Father Sister Brother Daughter Son Other Stroke (CVA) Self Mother Father Sister Brother Daughter Son Other Depression Self Mother Father Sister Brother Daughter Son Other Thyroid, Under Active Self Mother Father Sister Brother Daughter Son Other Diabetes, Type 1 (child) Self Mother Father Sister Brother Daughter Son Other Thyroid, Hyper Active Self Mother Father Sister Brother Daughter Son Other Diabetes, Type 2 (adult) Self Mother Father Sister Brother Daughter Son Other Tuberculosis/PPD+ Self Mother Father Sister Brother Daughter Son Other Epilepsy (Seizures) Self Mother Father Sister Brother Daughter Son Other Genetic Diseases Self Mother Father Sister Brother Daughter Son Other GI Diseases Self Mother Father Sister Brother Daughter Son Other Other Self Mother Father Sister Brother Daughter Son SURGICAL AND PROCEDURAL HISTORYPlease list all prior operations and/or procedures with dates (excluding dental surgeries/procedures): I have had no prior surgery ListOperationDate HOSPITALIZATIONS IN THE LAST YEARPlease list all prior hospitalizations within the last year: I have had no hospitalizations this past year ListReason for Hospital StayDate GENERAL HEALTH QUESTIONSDate of your last colonoscopy: Date Format: MM slash DD slash YYYY Result of colonoscopy:WOMEN’S GYNECOLOGIC HISTORY Not Applicable When was your last mammogram? Date Format: MM slash DD slash YYYY Results:# of Pregnancies:# of Deliveries:# of Abortions:# of Miscarriages:Menstrual Cycle:1st day, most recent period:Age at 1st period:Frequency:Length:Do you have any concerns about your periods?YesNoPlease Explain:Do you have any concerns about menopause?N/AYesNoSpecify What:If you have stopped having periods, please specify age when you reached menopause:When was your last Pap Test? Date Format: MM slash DD slash YYYY Have you ever had an abnormal Pap test?YesNoSpecify When: Date Format: MM slash DD slash YYYY Are you currently on birth control?YesNoIf currently on birth control, what method are you using?MEN’S HEALTH HISTORY Not Applicable When was your last Prostate Exam? Date Format: MM slash DD slash YYYY Results:Have you had any Prostate problems?YesNoIf yes, specify whenDid you have any treatment?YesNoIf yes, list:Do you have concerns about erectile dysfunction?YesNo SOCIAL HISTORYAdvanced DirectiveSleepDo you have an Advanced Directive?YesNoDo you have trouble sleeping at night?YesNoWould you like to create one?YesNoAbout how many hours a night do you sleep?Employment StatusSafetyCurrent Status:Full TimePart TimeNot EmployedDo you use seatbelts consistently?N/AYesNoHow Long?Do you use a bike helmet regularly?N/AYesNoOccupation:Is violence at home a concern for you?YesNoAny Occupational Risks?Are you currently in a relationship?YesNoIf yes, do you feel safe in this relationship?YesNoIf not employed, are you registered disabled?YesNoDo you have a gun in your home?YesNoCivil StatusMarial StausSingleMarriedWidowedDivorcedDomestic PartnershipFor how long:Partners Name:StressHow often is stress a problem for you in handling such things as:Your health?AlwaysOftenSometimesNeverYour finances?AlwaysOftenSometimesNeverYour work?AlwaysOftenSometimesNeverYour family or social relationships?AlwaysOftenSometimesNeverEducation Education Level CompletedLess than High SchoolHigh SchoolCollegeGraduate SchoolExerciseHow active are you?I get a cardiovascular work-out 3 or more times/ weekI walk daily but do not work outI exercise or walk less than 3 times/ weekI am not generally activeEmotions Please rate each question, using the following scale: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every dayOver the past two weeks, how often have you been bothered by any of the following problems?1) Little interest or pleasure in doing things?Please enter a number from 0 to 3.2) Feeling down, depressed or hopeless?Please enter a number from 0 to 3.Tobacco UsePlease choose one:I have never smoked.I have smoked, but rarely.I have quit smoking.I currently smokeWhen was the last time?Quit Date: Date Format: MM slash DD slash YYYY Other Tobacco: Pipe Cigar Snuff Chew Are you interested in quitting?YesNoN/AHistory:Number of Pack a Day:Number of Years Smoking:Drug UseDo you use any recreational drugs?YesNoHave you ever used needles?YesNoAlcohol UseDo you drink alcohol?NeverOccasionallyRegularlyTypes of Drinks:5oz wine12oz beer1.5oz hard liquorIs alcohol use a concern for you or others?YesNoAverage # drinks per day:Average # drinks per week:Sexual ActivitySexually Active:YesNoNot CurrentlyIf sexually active, do you practice safe sex?YesNoCurrent sex partner(s) is/are:MaleFemaleBothHave you ever had any sexually transmitted diseases (STDs)?YesNoListType:Date: Are you interested in being screened for STDs?YesNoSocial/Emotional SupportWho do you live with?How often do you get the social and emotional support you need?AlwaysOftenSometimesNeverRecreational and Social Activities In the past 3 months:How often have you done activities that you enjoy?OftenSometimesRarelyNeverHow often do you spend time with family and friends?OftenSometimesRarelyNeverList Activities:Transportation NeedsIn the past 12 months, has lack of transportation kept you from any of the below activities? (Check all that apply) Yes, it has kept me from medical appointments or getting medications Yes, it has kept me from non-medical meetings appointments, work, or getting things that I need No Food InsecurityWithin the past 12 months, you worried whether your food would run out before you got money to buy more.OftenSometimesNeverDon’t Know / RefusedWithin the past 12 months the food you bought just didn’t last and you didn’t have money to get more.OftenSometimesNeverDon’t Know / RefusedBy signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate. Patient/Legal Guardian Signature:Date Date Format: MM slash DD slash YYYY Welcome to San Diego Internal Medicine! Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Below are our office and financial policies. Please read it, ask us any questions you may have, and sign it in the space provided. A copy will be provided to you upon request.Practice Policies Phones: Telephones are answered Monday through Friday 8:00am – 5:00pm (except on certain holidays). Emergencies: Our practice has a physician on-call for patient emergencies that may occur after hours. If a problem arises during a time when the office is closed, simply call the office at (858)541-0181 and the answering service will connect you with the physician on call. Your call will be returned in a timely manner. Please note that prescription refills and referrals are not considered emergencies and will not be done after hours. Patient Portal: Our practice utilizes the secure on-line patient portal FollowMyHealth for enhanced patient communication. Through FollowMyHealth you can use your computer for appointment requests, review test results once your physician has reviewed the results. Prescriptions: All prescription refills request should be called in to your pharmacy. Your pharmacy will then contact our office if authorization is needed. Your refill requests will be handled within 48 hours after your pharmacy’s request is received. Prescriptions will not be called in after-hours or on weekends. Referrals: Referrals to other physicians or diagnostic facilities can take up to 72 hours for our office to process. Referrals will not be done after hours or on weekends. You are required to notify us at least 73 hours in advance of an appointment requiring a referral. Failure to do so may result in your referral being denied by your insurance company and therefore making you responsible for any charges incurred at the specialist’s office. Test Results: Should you have any laboratory work diagnostic testing done through our practice, you will be notified of the results as soon as they are available (usually within 5 business days from the test date). All results must be reviewed by the physician. You will then receive a call from the physician’s medical assistant or a letter in the mail with physician’s instructions. Medical Records: It takes our office 7 business days to process record requests. Records will be released to a physician upon written authorization. There is no charge for this. There is a charge for personal records requests. The usual fee is $15 for the first ten pages and $0.50 for each additional page. Form Completion: Our office charges for the completion of forms. These charges will be your responsibility and will be billed to you. Please note these fees cannot be billed to your insurance and are due at the time of service. Co-Payments: Your insurance company requires us to collect co-payments at the time of service. Waive of co-payments may constitute fraud under state and federal law. Please help us in upholding the law by paying your co-payments at each visit. Deductible Payments: If your insurance requires you to meet a deductible before services are covered, payment must be made at the time of service. A $100 payment will be due at the time of service. Please note the $100. Payment does not constitute payment in full and any additional balance must be paid upon receiving notification from our practice. Claims Submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Payment from your insurance company is expected within 45 days. After 45 days, we will look to you for payment in full. You will be responsible for all non-covered services according to Medicare guidelines. We must have a copy of your most recent cards and any secondary insurance or supplement you may have. Accounts that are 90 days past due are subject to being sent to a collection agency or small claims court for the unpaid bills. If we receive notification that you are not eligible for coverage or we are not contracted with your insurance, you will be responsible for all charges incurred. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Preventative Care Services: Routine exams are not always covered by your insurance. Please be aware that if an additional problem is addressed at the time of your visit, a copay, deductible, or office visit fee may be charged. If services are denied for payments by your insurance or you have failed to provide us with your correct insurance information, you will be responsible to pay for these services. Cash Pay Patients: The amount paid for today’s scheduled visit may not be your final payment. Other costs that may be accrued for today’s appointment are including but not limited to, laboratory tests, x-ray test, any injections, special procedure or additional office visit charges. Laboratory Bills: Any laboratory procedures that are ordered will be billed to you directly by the laboratory. Please contact your laboratory directly for any questions regarding your lab bill. Missed Appointments: Please note a $25. Cancellation fee will apply for missed appointments or failure to cancel within 24 hours prior to your scheduled appointment time. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regular scheduled appointment. After 3 missed appointments, you will receive a certified letter that SDIMA will no longer be able to serve as your primary healthcare provider. We will continue serving you for the next 30 days until you find a new provider. Late Arrivals: If you arrive more than 5 minutes late to your scheduled appointment, you may be asked to reschedule for the next available appointment that day, due to consideration for other patients in the practice. We do our best to accommodate all our patients and realize that situations do arise that can encumber a punctual arrival. If at any time you should experience financial hardship and need to make special payment plan arrangements, please contact our billing department. Practice PoliciesAssignment of benefits Authorization is hereby granted to release information as may be necessary to process and complete my insurance claim, and payment of medical benefit is to be paid directly to the physician for all services rendered.Initials:I have read and received a copy and understand the above statements. I agree to comply with the financial policies of the office, and I am financially responsible for my account. PatientPatient Name First Last Date of Birth Date Format: MM slash DD slash YYYY SignatureToday's Date Date Format: MM slash DD slash YYYY FollowMyHealth is a great way to manage your health care from your computer, tablet or smartphone. You will be able to: You will be able to: Send and receive messages from your doctor’s office Request and cancel appointments Review health information from your doctor or hospital visit, and more To sign up, all we need is your email address and an email will be sent to you automatically. The passcode to connect to our office will be your 4-digit birth year. Please note: Due to state and federal regulations, proxy accounts cannot be given to parents or guardians on behalf of patients between the ages of 12 to 17 years, who are able to make medical decisions for themselves. Those patients can be provided with their own accounts, and they can then give access to whomever they authorize.Patient's Name First Last Date of Birth Date Format: MM slash DD slash YYYY Patient's Email Address AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION Not Applicable Patient's Name First Last Date of Birth Date Format: MM slash DD slash YYYY Under the requirements of HIPAA (Patient Privacy Act) we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information released to family members, caregivers, or other you must sign this form. Signing this form will only give information to thespecified people listed below.You may speak to following people about my health and disclose my health information, that I have checked:Name of PersonDOBRelation to Patient You may disclose my (please check) Visit Notes Rendered Labs / X-rays HIV & Related Information Mental Health All Service & Treatment I have the right to revoke this authorization at any time by writing. This will be effective until that time.SignatureDate Date Format: MM slash DD slash YYYY *If over 30 pages PLEASE mail us the records and no CDs please*AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Not Applicable Name of Patient Full Name DOB Date Format: MM slash DD slash YYYY PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I hereby authorize the following entity to release my Protected Health Information (PHI):Name Full Name PhoneFaxAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Send records to the following entity or person:Name of Entity / Person Full Name PhoneFaxAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code INFORMATION REQUESTED:DATES OF SERVICE:From: Date Format: MM slash DD slash YYYY To: Date Format: MM slash DD slash YYYY Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.I authorize release of information of the following portions of my medical record: Mental Health Substance Abuse HIV/AIDS Communicable Disease All I understand that this information shall be in effect for 180 days following the date of signature. However, I understand that this authorization may be revoked at any time by giving oral or written notice to the medical office. A photocopy of this authorization shall constitute a valid authorization. I understand that once my medical records have been released, the medical office cannot retrieve them and has no control over the use of the already releases copies. Should my case require review by a governing agency or another medical profession actively involved in my care to make a final determination, it is with my consent that a copy of these records will be submitted to the agency or medical profession for this review.Signature of Patient (or legal representative)Date Date Format: MM slash DD slash YYYY
