Flint Hills Heart, Vascular and Vein Clinic
Raymond Dattilo, M.D., F.A.C.C.
Ph: (785) 320-5858
Fax: (785) 320-5689
Ans Serv: (800) 673-6664

Manhattan, Kansas

Forms: You may print these out and keep or bring to your appointment



Flint Hills Heart, Vascular and Vein Clinic, LLC

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

 

If you have any questions about this Notice please contact

our Privacy Officer 

 

 

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

 

We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

 

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

 

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you.  Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.

 

Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

 

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.

 

Payment:  Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.  

 

Health Care Operations:  We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.

 

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

 

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You may contact our Privacy Officer to request that these materials not be sent to you.

 

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

 

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object  

 

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object.  These situations include:

 

Required By Law:  We may use or disclose your protected health information to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, if required by law, of any such uses or disclosures. 

 

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

 

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

 

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.  

 

Abuse or Neglect:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

 

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. 

 

Legal Proceedings:  We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.  

 

Law Enforcement:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.  

 

Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

 

Research:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

 

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.  

 

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.  

 

Workers’ Compensation:  We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

 

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

 

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

 

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization in writing at any time.  If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization.  Please understand that we are unable to take back any disclosures already made with your authorization.

 

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

 

We may use and disclose your protected health information in the following instances.  You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.  If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest. 

 

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation.  All of this information, except religious affiliation, will be disclosed to people that ask for you by name.  Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.

 

Others Involved in Your Health Care or Payment for your Care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

 

 

2. YOUR RIGHTS

 

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. 

 

You have the right to inspect and copy your protected health information.  This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information.  You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.  As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.  

 

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed.  Please contact our Privacy Officer if you have questions about access to your medical record.  

 

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.  

 

Your physician is not required to agree to a restriction that you may request.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction by [describe how patient may obtain a restriction.]  

 

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

 

You may have the right to have your physician amend your protected health information.   This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Please contact our Privacy Officer if you have questions about amending your medical record.   

 

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure.  You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.  

 

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 

 

3. COMPLAINTS

 

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our Privacy Officer of your complaint.  We will not retaliate against you for filing a complaint. 

 

You may contact our Privacy Officer, for further information about the complaint process.  

 

This notice was published and becomes effective on June 1, 2013.

 

 

 


Flint Hills Heart, Vascular and Vein Clinic, LLC

 

 Protected Health Information Management 

In general, the HIPPA Privacy Rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). Individuals have the right to request receipt of confidential communications from us by alternative means or at alternative locations. 

 

I wish to be contacted in the following manner: (check all that apply) 

 

Home Telephone __________________________ ? Written Communication 

OK to leave message with detailed information OK to mail to my home address 

Leave message with call-back number ONLY OK to mail to my work/office address 

      OK to fax ____________________________ 

Work Telephone __________________________ 

OK to leave message with detailed information Other (email, cell phone, etc.) _________________________ 

Leave message with call-back number ONLY 

 

HIPPA Privacy Policy Notice

I hereby acknowledge that I have reviewed Dr. Dattilo’s HIPPA Privacy Policy Notice. I understand that I may request additional copies of this at any time.

 _____________________________________________     ___________________________

 Print Patient’s Name or Patient’s Guardian/Representative            Patient’s Date of Birth

___________________________________________ 

Signature of Patient or Patient’s Guardian/Representative 

___________________________________________

Guardian/Representative’s Relationship to Patient

____________________ 

Date

 

 

 


 

Raymond Dattilo, MD, FACC

Flint Hills Heart, Vascular, and Vein Clinic

3905 Vanesta Drive

Manhattan, Kansas 66503

Phone: 785-320-5858  Fax: 785-320-5689

 

Authorization for Release of Information

**Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.

Parts 160 and 164)**

 

Date Requested: _______________    Patient Name: ___________________________________________

 

Date of Birth: __________________   Phone Number: __________________________________________

 

Address: _______________________________________________________________________________

 

Entities who are authorized to release the records

o Flint Hills Heart, Vascular, and Vein Clinic

o Other____________________________________________________________________________

 

Entities who are authorized to receive the records

o Flint Hills Heart, Vascular, and Vein Clinic

o Other ____________________________________________________________________________

 

Requested Method of Delivery:    Mail                 Fax (___) __________                      Patient Will Pick Up

 

Information to be released:         Complete copy of medical records

(please check all that apply)       Date Range: From _______________________       To __________________

                                                         Only Diagnosis & Treatment Records Pertaining to: ____________________

                                                         Disc of images and study reports

 

1. This authorization shall be in forced and effective until ___________________ (date or event), at which time this authorization expires.

2. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

3. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be condition on whether I sign this authorization.

5. I understand that if the person or entity that receives the described records or information is not a health care provider or health plan covered by federal privacy regulations, the records/information may be redisclosed and no longer protected by the regulations.

 

 

_________________________________________________________           ______________

Signature of Patient or Personal Representative     Date

 

________________________________________________________

Printed Name of Patient or Personal Representative

 

________________________________________________________

Personal Representative Relationship to Patient

 

________________________________________________________

Printed Address & Telephone Number of Personal Representative

 

 

 


 

AUTHORIZATION AND CARE/RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

 

CONSENT TO TREAT

The term “health care provider(s)” in this document means Flint Hills Heart Vascular and Vein Center, LLC, its agent and employees, members of the medical staff, their agents and employees and other health care practitioners who provide care to patients.

 

I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plan for care including future treatment.  I understand that this information serves as:

1. Basis for planning my treatment and care

2. Information used to file my claim with the insurance company (procedure and diagnosis)

3. Means by which a third-party payer can verify that billed services were actually provided

4. A tool for routine health care operations including assessing quality and reviewing competency of your staff and/or other health care providers

I understand that I have reviewed the Notice of Information Practices that provides more complete information of uses and disclosures.  I understand that I have the right to review the notice before signing the consent.  I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided.  I understand that I have the right to restrict how my health information may be used or disclosed to carry out payment, treatment, or health care operations and that the organization is not required to agree to the restrictions requested.  I understand that Permission is hereby granted to all health care providers involved in my care to administer such examination, treatment, testing, and procedures as are deemed necessary in the course of my care.

RELEASE OF INFORMATION

Information about me necessary to substantiate my insurance claims may be release by the health care provider involved in my case.

 

FINANCIAL RESPONSIBILITY/ASSIGNEMENT OF BENEFITS

For those health care providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to pay directly to that provider any benefits of any policies of insurance to those health care providers who have rendered services to me and who accept such assignment.  I agree to pay all charges that are not paid in full by assigned insurance.  If such amounts due to the health care providers are not paid after reasonable notice, that account shall be deemed delinquent and a service charge may be added to the amount due.  In the event that I default on payment of my account, I agree to be responsible for collection fees and interest due on amounts in default, including court costs and reasonable attorney fees.  If the debt is assigned to a third party for collection, I agree to be responsible for collection fees and interest due on amounts in default.

 

MEDICARE LIFETIME BENEFICIARY CLAIM AUTHORIZATION AND RELEASE OF INFORMATION

I request that payment of authorized medical benefits be made either to me or on my behalf to Flint Hills Heart Vascular and Vein Center, LLC for any services furnished me by the physician/supplier.  I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine benefits or the benefits payable for related services.  

I understand my signature requests that payment be made and I authorize release of medical information necessary to pay the claim.  If other health insurance is indicated on item 9 of the CMS-1500 claim form or elsewhere on the approved claim form or electronically submitted claim, my signature authorizes release of information to the insurer or agency shown.  In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and noncovered services.  Co-insurance and deductible are based upon the charge determination of the Medicare Carrier.

 

 

__________________________________________________________________________________________

(Signature)                                                                                                                                                 (Date)

 

 

__________________________________________________________________________________________

(Witness)                                                                                 (Title)                                                         (Date)

 

 

 


Flint Hills Heart, Vascular and Vein Clinic, LLC

 

 

________________________________________

Name (please print)

 

 

_________________________

Date of Birth

 

 

AUTHORIZATION TO DISCUSS PROTECTED HEALTH INFORMATION

 

Through the Health Insurance Portability and Accountability Act (HIPPA), the Department of Health and Human Services established national standards for the privacy of protected health information (PHI). In compliance with these Federal regulations, Flint Hills Heart, Vascular, and Vein Clinic may not discuss your medical care with anyone without your expressed written permission, except in the case of an emergency or as required by law. This does not apply to disclosing information to carry out treatment, payment or health care operations.

 

Please list below the full names of people, along with phone numbers, with whom you give Flint Hills Heart, Vascular, and Vein Clinic authorization to discuss your case (i.e., medication refills, test results, appointment scheduling, billing information, medical history, etc.). Examples include spouse, parent(s), child, sibling, significant other, friend, interpreter, etc.

 

If you choose not to name anyone, please indicate “NO ONE.”

 

 

1. ______________________________________________________________________________

 

 

2. ______________________________________________________________________________

 

 

3. ______________________________________________________________________________

 

 

4. ______________________________________________________________________________

 

 

 

______________________________________________                            __________________________

Signature               Date

 

 

 


Flint Hills Heart, Vascular and Vein Clinic, LLC

New Patient Registration Form

 

 

Patient Name:_______________________________     Social Security Number: _____-______-______

Date of Birth: ____/_____/_____ Sex: M/F (Circle One) Married/Single/Divorced/Widow

Address: ____________________________________________________________________________

(Street) (City/State/Zip)

Home Phone:  (____) ______-__________ E-Mail Address: _______________________________

Cell Phone: (          )              -__________

Employer Name: __________________________      Employer Phone Number: (____) ______-_______

Primary Care Physician: ___________________________________         

(Name)

How did you hear about our practice? ______________________________________________________

 

Preferred Pharmacy:____________________________________  __________________________

(Name) (Phone)

                                    ___________________________________________________________________

(Address)

Person responsible for bill (Complete only if different from patient)

Guarantor Name: ________________________________     Social Security Number: _____-____-_____

Relationship to Patient: (please check): ( )Self, ( ) Spouse, or ( ) Parent         Date of Birth: ___-___-_____

Address: __________________________________________________ Phone Number: ____________

Employer Name: _______________________   Employer Phone Number: (____) _______-_________

Employer Address: _____________________________________________________________________

                     (Street) (City/State/Zip)

Who to call for an emergency:

Name: _____________________________Address: __________________________________________

Home Phone: (____) _____-________ Work Phone: (____) _____-______ Relationship: ____________

Primary Insurance Information (We will also need a copy of your insurance cards for our records)

Plan Name: ___________________________               I.D. Number: _____________________________

Address: ________________________________________              Group Number: _________________

Policy Holder: ____________________________        Effective Date: _______________________

Policy Holder’s Social Security Number: ______-_____-_______   Sex:  M / F

 

Secondary Insurance Information

Plan Name: ___________________________               I.D. Number: _____________________________

Address: ________________________________________              Group Number: _________________

Policy Holder: ____________________________        Effective Date: _______________________

Policy Holder’s Social Security Number: ______-_____-_______   Sex:  M / F

Tertiary Insurance Information

Plan Name: ___________________________               I.D. Number: _____________________________

Address: ________________________________________              Group Number: _________________

Policy Holder: ____________________________        Effective Date: _______________________

Policy Holder’s Social Security Number: ______-_____-_______    Sex:  M / F

 

IS YOUR VISIT DUE TO A JOB RELATED INJURY OR AUTOMOBILE ACCIDENT?  Y___  N __

IF YES, PLEASE NOTIFY THE RECEPTIONIST.

 

 

 


 

FLINT HILLS HEART, VASCULAR AND VEIN CLINIC, LLC

 

PATIENT HISTORY FORM

 

Date: _______/_________/________

NAME: Birthdate: _____/______/_____

Last First M. I.

Age:___________ Sex: • F • M

 

How did you hear about this clinic?

Describe briefly your present symptoms:

 

 

Please list the names of your PCP and other practitioners you may have seen for this problem:

 

 

Heart or Vascular Hospitalizations (include where, when, & for what reason):

 

 

Have you ever had a heart attack?                       Have you had angioplasty or stent? Where?

 

CURRENT MEDICATIONS

Drug allergies:  • No   • Yes   To what?

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Name of drug Dose (include strength & number of pills per day)       How long have you been taking this?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

 

 

 

PAST MEDICAL HISTORY

Do you now or have you ever had:

• Diabetes • Heart murmur • Family history of heart or     vascular disease

• High blood pressure • Pneumonia • Colitis

• High cholesterol • Pulmonary embolism • Anemia

• Hypothyroidism • Asthma • Jaundice

• Cigarette smoking • Emphysema • Hepatitis

• Cancer (type) _________________ • Stroke • Stomach  or peptic ulcer

• Foot or leg ulcers • Epilepsy (seizures) • Rheumatic fever

• Leg swelling • Cataracts • Vascular disease

• Angina • Kidney disease • HIV/AIDS

• Heart problems • varicose veins

Other medical conditions (please list):

 

 

 

 

 

PERSONAL  HISTORY

Do you use illicit drugs or alcohol? How much?

Where were your born & raised?

What is your highest education? •High school   •Some college   •College graduate   •Advanced degree

Marital status: • Never married  • Married  • Divorced  • Separated  • Widowed  • Partnered/significant other

What is your current or past occupation?

Are you currently working? :  • Yes  • No   Hours/week ______ If not, are you • retired  • disabled  • sick leave?

Do you receive disability or SSI?  • Yes  • No   If yes, for what disability & how long?___________________________

 

FAMILY HISTORY

IF LIVING IF DECEASED

Age (s) Health Age(s) at death Cause

Father

Mother

Siblings

 

 

Children

 

 

Have either of your parents had a heart attack before the age of 60?

Have either of your parents or siblings suffered from varicose veins or swollen legs?

 

 

 

 

 

 

 

 

SYSTEMS REVIEW

 

In the past month, have you had any of the following problems?

GENERAL NERVOUS SYSTEM PSYCHIATRIC 

• Recent weight gain; how much____ • Headaches • Depression

• Recent weight loss: how much____ • Dizziness • Excessive worries

• Fatigue • Fainting or loss of consciousness • Difficulty falling asleep

• Weakness • Numbness or tingling • Difficulty staying asleep

• Fever • Memory loss • Difficulties with sexual arousal

• Night sweats • Poor appetite

• Food cravings

MUSCLE/JOINTS/BONES STOMACH AND INTESTINES • Frequent crying

• Numbness • Nausea • Sensitivity

• Joint pain • Heartburn • Thoughts of suicide / attempts

• Muscle weakness • Stomach pain • Stress

• Discomfort in your legs when you walk? •  Vomiting • Irritability

• Yellow jaundice • Poor concentration

• Increasing constipation • Racing thoughts

EARS • Persistent diarrhea • Hallucinations

• Ringing in ears • Blood in stools • Rapid speech

• Loss of hearing • Black stools • Guilty thoughts

• Paranoia

EYES SKIN • Mood swings

• Pain • Redness • Anxiety

• Redness • Rash • Risky behavior

• Loss of vision • Nodules/bumps

• Double or blurred vision • Hair loss

• Dryness • Color changes of hands or feet OTHER PROBLEMS:

THROAT BLOOD

• Frequent sore throats • Anemia

• Hoarseness • Clots

• Difficulty in swallowing

• Pain in jaw KIDNEY/URINE/BLADDER

• Frequent or painful urination

HEART AND LUNGS • Blood in urine

• Chest pain

• Palpitations Women Only:

• Shortness of breath • Abnormal Pap smear

• Fainting • Irregular periods

• Swollen legs or feet • Bleeding between periods

• Cough • PMS

WOMENS REPRODUCTIVE HISTORY:

Age of first period:

# Pregnancies:

# Miscarriages:

# Abortions:

Have you reached menopause?  Y /  N    At what age?

Do you have regular periods?      Y /  N    

 

 

 

 

SUBSTANCE USE

 

DRUG CATEGORY

 

(circle each substance used) Age when 

you first 

used this: How much & how often did you use this? How many years did you use this?

 

When did 

you last 

use this?

 

Do you currently

use this?

 

     ALCOHOL   Yes ?         No ?

CANNABIS:

Marijuana, hashish, hash oil   Yes ?         No ?

STIMULANTS:

Cocaine, crack   Yes ?         No ?

STIMULANTS:

Methamphetamine—speed, ice, crank   Yes ?         No ?

AMPHETAMINES/OTHER STIMULANTS:

Ritalin, Benzedrine, Dexedrine   Yes ?         No ?

BENZODIAZEPINES/TRANQUILIZERS:

Valium, Librium, Halcion, Xanax, Diazepam, “Roofies”   Yes ?         No ?

SEDATIVES/HYPNOTICS/BARBITURATES: 

Amytal, Seconal, Dalmane, Quaalude, Phenobarbital   Yes ?         No ?

HEROIN   Yes ?         No ?

STREET OR ILLICIT METHADONE   Yes ?         No ?

OTHER OPIOIDS: 

Tylenol #2 & #3, 282’S, 292’S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid

  Yes ?         No ?

HALLUCINOGENS: 

LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide

  Yes ?         No ?

INHALANTS: 

Glue, gasoline, aerosols, paint thinner, poppers, rush, locker room   Yes ?         No ?

OTHER: specify)_________________________________________________________________________________________________________   Yes ?         No ?