Social Security # :

Name (Last, First, MI):

Date:

Check All That Apply:
Married Single Minor Male Female

Address:

City:

State:   Zip:

Birthdate (Mo/Day/Year):

Home Phone:

Work Phone:

Fax:

E-Mail:

Employer:

Referring Physician :

How did you hear of us?:

Commercial Medicaid Medicare
 
Worker's Compensation

Other:

Insurance Co:

Insured/Card Holder's Name:

Relationship:

Policy#:

Group#:

Phone:

Secondary Insurance Information

Commercial Medicaid Medicare
 
Worker's Compensation

Other:

Insurance Co:

Insured/Card Holder's Name:

Relationship:

Policy#:

Group#:

Phone:

Company Name:

Supervisor's Name:

Company Phone:

Supervisor's Phone:

Social Security # :

Sex: Male Female

Name:

Home Phone:

Work Phone:

Social Security # :

Relationship:

Name (Last, First, MI):

Address:

City:

State:   Zip:

Birthdate (Mo/Day/Year):

Sex: Male Female

Daytime Phone:

Employer:

Address:

City:

State:   Zip:

I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services.

Authorization to release information

I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims.

Signature:

Patient or Responsible Party

Date:

Patient Questionnaire

Drug Allergies:

Heart Disease Risk Factors

Do you currently smoke? Yes No

Have you smoked in the past? Yes No

If so, how many years?

Have you ever had an elevated cholesterol level on blood tests? Yes No

Do you drink alcoholic beverages? Yes No

If so, how much?

Have you ever been told you have an elavated blood sugar (diabetes)? Yes No

Have you ever taken oral contraceptives and/or supplemental hormones? Yes No

If so, how many years?

Do you excercise regularly? Yes No

If so, please describe?

Cardiovascular History

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the Internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.