ADULT INFORMATION SHEET - entnorthmississippi.comparkinson’s chronic sore throat / tonsillitis...

DATE: ________________________________________ DOCTOR _____________________________________

TIME _________________________________________

ADULT INFORMATION SHEET

FULLNAME _________________________________________________________________________________________

NICKNAME: __________________ SEX: ________ BIRTHDATE: _____________ AGE: _________________

SOCIAL SECURITY #: __________________ HOME PHONE #: ____________ CELL PHONE #: __________

MAILING ADDRESS: STREET ____________________________________________________________________

CITY: _______________________________ STATE: ____________ ZIP: _____________________

PLACE OF EMPLOYMENT: _____________________ E-MAIL ADDRESS: ______________________________

OCCUPATION: ________________________________ WORK PHONE #: ________________________________

__________ SINGLE ________ MARRIED _______ WIDOWED ______ SEPARATED _______ DIVORCED

SPOUSE’SFULL NAME: ___________________________________________________________________________________

LAST FIRST MI

BIRTHDATE: __________________________________ SOCIAL SECURITY #: __________________________

SPOUSE’S PLACE OF EMPLOYMENT ___________________________ EMAIL: _________________________

OCCUPATION _________________________________________ WORK PHONE: __________________________

HOW WOULD YOU LIKE TO BE NOTIFIED FOR APPOINTMENT CONFIRMATION?

❑ EMAIL ❑ PHONE

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

** HOW DID YOU HEAR ABOUT OUR CLINIC? _____________________________________________________

** WHO IS RESPONSIBLE FOR THIS BILL? _________________________________________________________

** WHICH PHYSICIAN REQUESTED THIS CONSULTATION? ______________ CITY/STATE _____________

** FAMILY DOCTOR? _________________________________________________ CITY/STATE _____________

** WHO CAN WE CONTACT IN CASE OF EMERGENCY? _____________________________________________

RELATIONSHIP: _______________________________ PHONE #: _____________________________________

** I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATIO NNECESSARY TO PROCESS ANY CLAIMFILED OR RELEASE MEDICAL RECORDS ON MY BEHALF.

** I ALSO ASSIGN ANY BENEFITS FROM MY INSURANCE COMPANY LISTED ABOVE TO THE PHYSICIANFOR SERVICES DESCRIBED ON THE CLAIM FORM.

FINANCIAL AGREEMENT: I fully understand that I am ultimately responsible for any and all charges associated withmy account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court costs, attorneyfees, and any other charges incurred in the collection of any balance due.

SIGNED: _______________________________________________________ DATE: _______________________

SPRINTPRINT — 662-841-9292

OF3

• PATIENTNAME:____________________________________________DATEOFBIRTH:__________________NEVERSMOKER:X CURRENTSMOKER:completebelow FORMERSMOKER:completebelow #PacksPerDay: YearYouQuit:SMOKELESSTOBACCO? #CigarettesPerDay: #PacksPerDayUsedtoSmoke: HowManyYearsSmoking?: #YearsYouSmoked:

DRINKALCOHOL:NO:____YES:____(ifyescompletebelow)1.___SOCIALLY2.____INFREQUENTLY3.___FREQUENTLY 1.BEER___2.LIQUOR___3.WINE___ #DrinksperWeek_________#DrinksPerMonth_________

• RECREATIONALDRUGUSE?Yes/No:(LISTTYPE):_________________________________________• SURGERIES:LISTALLSURGERYTHATTHEPATIENTHASHAD:_________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DateofLastFluShot,MONTHANDYEAR: DateofLastPneumoniaShot,MONTHANDYEAR:

• FAMILY(Mother,Father,Sister,Brother,Daughter,Son)MEDICALHISTORY:(M)Mother;(F)Father;(S)Sister;(B)Brother;(D)Daughter;(SON)Son

ADOPTEDHISTORYUNKNOWN ALLERGICRHINITIS FOODALLERGY-(LIST) PETALLERGY ALZHEIMER’S ARTHRITIS ASTHMA AUTISM CORONARYARTERYDISEASE COPD CANCER(LISTTYPE): DIABETES GERD(ACIDREFLUX) FIBROMYALGIA HEADACHES/MIGRAINES HEARINGLOSS HEARTDISEASE HIGHBLOODPRESSURE KIDNEYDISORDER MENIERE’SDISEASE

SLEEPAPNEA PARKINSON’S SEIZURES SKINDISORDER CHRONICSINUSPROBLEM STROKE THYROIDDISORDER VERTIGO(dizziness)

COMPLETENEXT2PAGES

• PATIENT’SMEDICALCONDITIONS(NONE):_________PAGE2OF3

(X)CURRENT(X)PAST(X)CURRENT(X)PAST

ADHD CANCER(LISTType):

ALCOHOLISM ALLERGICRHINITIS

ALLERGYTESTS EGGALLERGY

MILKALLERGY PEANUTALLERGY

PETALLERGY SEAFOODALLERGY

ALZHEIMER’S ANEMIA

ANXIETY ARTHRITIS/RHEUMATOIDARTHRITIS

ASTHMA ATRIALFIBRILLATION

AUTISM NECKPAIN

CHESTPAIN CONGESTIVEHEARTFAILURE

COPD CORONARYARTERYDISEASE

DENTALCAVITIES DEPRESSION

DIABETES EMPHYSEMA

FIBROMYALGIA TOBACCOSMOKEEXPOSUREATHOME

GERD(ACIDREFLUX) GRAVE’SDISEASE

HEARINGLOSS HEARTATTACK

HEARTDISEASE HIGHBLOODPRESSURE

HEPATITIS(Type): HUMANIMMUNODEFICIENCYVIRUS/HIV HIGHCHOLESTEROL HIGHLIPIDS

IMPACTEDEARWAX INSOMNIA

IRRITABLEBOWELSYNDROME KIDNEYDISORDER

LARYNGEALCANCER HOARSENESS

LUPUS MENIERE’SDISEASE

MIGRAINES MITRALVALVEDISORDER

OSTEOARTHRITIS OSTEOPOROSIS

EARINFECTIONS,CHRONIC SLEEPAPNEA:CPAPorBIPAP

PARKINSON’S CHRONICSORETHROAT/TONSILLITIS

SEIZUREDISORDER SKINDISORDER

SINUSINFECTION STROKE

PARAthyroidDISORDER THYROIDDISORDER:Nodule,HYPOthyroid,HYPERthyroid;Goiter

VERTIGO(DIZZINESS) VISUALIMPAIRMENT:Glasses,Contacts

CURRENTSMOKER SEXUALLYTRANSMITTEDDISEASE

OTHERCONDITION-PLEASELIST: OTHERCONDITION: COMPLETENEXTPAGE

OF3

• NAME&LOCATIONOFYOURLOCALPHARMACY:

NameofPharmacy:

LocationofPharmacy:

• ALLERGICTO:LISTBELOWALLMEDICINETHEPATIENTISALLERGICTO:

• MEDICATION:LISTBELOWALLMEDICINETHEPATIENTISPRESENTLYTAKING:1.NAMEOFMEDICATION2.DOSAGE/Milligrams3.HOWMANYTIMESPERDAY

FINALPAGE

Ear, Nose and Throat Physicians, P.A.

Consent for Treatment

Patient Name: ________________________________________________

Date of Birth: ________________________________________________

Relationship to Patient: ________________________________________

CHILDREN (FAMILY MEMBERS ONLY)

PLEASE LIST ALL PERSONS THAT MAY BRING YOUR CHILD TO OUR CLINIC AND THAT WEMAY TALK TO REGARDING YOUR CHILD’S CARE AND TREATMENT:(EXAMPLE: GRANDPARENTS, AUNTS/UNCLES, ETC.)

______________________________________ ______________________________________

______________________________________ ______________________________________

______________________________________ ______________________________________

ONLY PARENTS OR LEGAL GUARDIANS MAY SIGN CONSENTS FOR SURGERY OR GETCOPIES OF MEDICAL RECORDS.

ADULTS (FAMILY MEMBERS ONLY)

PLEASE LIST ALL PERSONS WHO MAY HAVE ACCESS TO YOUR MEDICAL RECORD:

______________________________________ ______________________________________

______________________________________ ______________________________________

______________________________________ ______________________________________

___________________________________________________________________________________SIGNATURE OF PATIENT, PARENT, OR GUARDIAN DATE

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ADULT INFORMATION SHEET - entnorthmississippi.comparkinson’s chronic sore throat / tonsillitis...

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