Southland Rheumatology New Patient Packet

Patient Name:

Patient First Name

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Patient Last Name

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Middle Initial:

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Date of Birth:

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Gender:

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Marital Status:

Single

Married

Divorced

Widow/Er

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Address:

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City:

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State:

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Zip Code:

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Cell Number:

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Home Number:

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Social Security:

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Ethnicity:

Hispanic

Non-Hispanic

Decline

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Language:

English

Spanish

Other

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Patient Employer

Patient Employer:

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Employer Address:

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Phone Number:

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Person Responsible for Bill:

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Date of Birth:

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Address (if different than patient):

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Pharmacy Name:

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Address:

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City:

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State:

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Zipcode:

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Permission to view Prescription History from External Sources:

Yes

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Primary Care Physician

Name:

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Referred By (If different from your PCP):

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Emergency Contact

Contact Name:

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Contact Relationship:

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Contact Number:

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Contact Address:

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Insurance:

Primary Insurance

Name of Company:

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Subscriber Name:

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Subscriber DOB:

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Relationship:

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Policy Number:

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Group Number:

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Secondary Insurance

Name of Comapny

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Subscriber Name

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Subscriber DoB

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Relationship

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Policy Number

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Group Number

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I acknowledge receipt of notice of privacy practices (HIPAA) is on the above website and copy of it for the review is available upon request.

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I authorize Southland Rheumatology Center to release information regarding services rendered and allow a photocopy of my signature to be used to file insurance.

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I authorize and direct my insurer to issue payment for services directly to Southland Rheumatology Center. If my insurance is MEDICARE, I request the payment of authorized MEDICARE benefits, for any services furnished to me, to be made on my behalf, to Southland Rheumatology Center.

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In the event of non-payment, I understand that I am responsible for collection, attorney, and court costs.

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I authorize any holder of medical information about me to release to the HEALTHCARE FINANCING ADMINISTRATION and its agents any information needed to determine those benefits payable for related services.

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Dr. Nayak is NOT a MEDICAID Provider.

FAILURE TO PROVIDE SECONDARY INSURANCE INFORMATION PRIOR TO VISITS WILL RESULT IN PATIENT BEING RESPONSIBLE FOR BALANCE ON ACCOUNT.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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Patient Medical History

What is the reason for your visit today?

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Pain Level: Please indicate how severe your pain has been OVER THE PAST WEEK from scale 1-10?

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Please list any RECENT Blood Test, X-Rays, MRI’s, CT scans and Other Studies done in last 6 months and WHERE they were done?

Type:

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Location:

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Date

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Type:

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Location:

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Date

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Type:

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Location:

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Date

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Type:

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Location:

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Date

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List All your Medications with Dosages including Over the Counter Non-Prescriptive Supplements.

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Do you have any allergies to medications?

Yes

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If yes, please list:

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List any MEDICAL CONDITIONS you have had, and Date of Diagnosis:

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List any SURGERIES you have had, and Date of Diagnosis:

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System Review

Please Check Any Symptoms You Are Currently Experiencing

Fever

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Chills

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Night Sweats

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Recent Weight Loss

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Recent Weight Gain

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Fatigue

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Difficulty Sleeping

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Neck Pain

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Back Pain

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Dry Eyes

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Double / Blurred Vision

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Ringing in Ears

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Frequent Nosebleeds

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Dry Mouth

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Frequent Mouth Sores

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Chest Pain

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Irregular Heartbeat

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High Blood Pressure

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Shortness of Breath

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Cough

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Wheezing

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Swollen Legs / Feet

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Changes in Mood

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Headaches

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Dizziness / Imbalance

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Fainting

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Tingling / Numbness

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Muscle Weakness

Please mark this checkbox.

Muscle Spasm

Please mark this checkbox.

Muscle Pain

Please mark this checkbox.

Difficulty Swallowing

Please mark this checkbox.

Heartburn

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Stomach Pain

Please mark this checkbox.

Diarrhea

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Constipation

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Nausea

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Memory Problems

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Loss of Appetite

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Thyroid Abnormalities

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Skin Rash

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Sun Sensitivity Rash

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Excessive Hair Loss

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Color Change in Hands / Feet

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Easy Bruising

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Pain / Burning / Frequent Urination

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Do you smoke?

Yes

Please select an option.

If yes, how much?

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Do you drink alcohol?

Yes

Please select an option.

If yes, how much?

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Do you use CBD?

Yes

Please select an option.

If yes, how much?

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Have you had Osteoporosis Screening w/Bone Density Test?

Yes

Please select an option.

If yes, when?

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Have you had a Pneumonia Vaccination?

Yes

Please select an option.

If yes, when?

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Have you had COVID-19 Vaccination?

Yes

Please select an option.

If yes, when?

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Have you had Shingles Vaccination?

Yes

Please select an option.

If yes, when?

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Family Health History

Father:

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Mother:

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Siblings:

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Children:

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Is there a Family Medical History of:

Autoimmune Connective Tissue Disease like Lupus or Rheumatoid Arthritis?

Yes

Please select an option.

If yes, who?

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Osteoarthritis:

Yes

Please select an option.

If yes, who?

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Gout / Kidney Stones:

Yes

Please select an option.

If yes, who?

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Osteoporosis:

Yes

Please select an option.

If yes, who?

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Cancer:

Yes

Please select an option.

If yes, who?

Please complete this field.

Heart Disease:

Yes

Please select an option.

If yes, who?

Please complete this field.

Diabetes:

Yes

Please select an option.

If yes, who?

Please complete this field.

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