PATIENT REGISTRATION FORM
Last Name: ______________________ First Name: __________________ Middle Initial: _____ Street Address: ________________________________________________________________ City: ______________________________ State: _________ Zip Code: __________________ Date of Birth: _______________________ E-Mail Address: _____________________________ Daytime Phone: _________________________ Evening Phone: ________________________ Emergency Contact Name & Phone Number: _________________________________________ Primary Care Physician’s Name: ___________________________________________________ Primary Care Physician’s Address: _________________________________________________ Primary Care Physician’s Phone Number: ___________________________________________ How did you hear about us? ______________________________________________________
Please note that Dr. Daniel Thomas, DO, MS and More T Clinics are not Medicare providers and do not accept third-party payment. Also, by supplying your email address, you are granting us permission to communicate with you by email for such things as lab results, appointment reminders, and answering your medical questions from time to time.
_________________________________________ _______________________ Patient Signature Date
MEDICAL HISTORY FORM
Name: ______________________________________________ Today’s Date: _________________ Date of Birth: __________________ Age: __________ Height: __________ Weight: __________ SYMPTOMS: Please check if you are experiencing any of the following:
Decreased Energy Decreased Sex Drive Difficulty Concentrating Lack of Mental Clarity Decreased Memory Difficulty Sleeping
Irritability or Grumpiness Sadness or Depression Anxiety
Decreased Motivation Weight Gain or Excess Fat Loss of Muscle or Strength
Joint Pain or Muscle Aches Migraine Headaches High Cholesterol Weak Erections
Other: _______________ _______________________ MEDICAL HISTORY:Please check if you have or have had any of the following:
Prostate Cancer Prostate Enlargement Breast Cancer
Hepatitis or Liver Disease Kidney Disease
Congestive Heart Failure Heart Attack
Coronary Angioplasty Heart Bypass Surgery Edema (swelling) Phlebitis or Blood Clots Taking Blood Thinners Sleep Apnea
Diabetes
Anxiety Depression Hair Loss
Thyroid Condition HIV Positive
Other: _______________ _______________________ Date of Last Prostate Exam: ________________________ Results: ____________________________ DO YOU HAVE ANY CONDITION THAT PREVENTS YOU FROM WALKING? No Yes
ILLNESSES OR CONDITIONS FOR WHICH YOU ARE CURRENTLY UNDER A DOCTOR’SCARE: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ PREVIOUS OPERATIONS INCLUDING COSMETIC SURGERY:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ CURRENT MEDICATIONS AND DOSAGES: Prescription and non-prescription, including aspirin, herbs, and vitamins:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
MEDICAL HISTORY FORM
cont’d
Name: _______________________________________________ Date of Birth: _________________ FAMILY HISTORY: Please list health problems of parents and siblings:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ALLERGIES:Medication or other: ________________________________________________________ DAILY ACTIVITY LEVEL: Sedentary Lightly Active Moderately Active Very Active
GOALS OF TREATMENT: Please check any of the following that you would like to achieve: Have more energy
Sleep well
Have better digestion
Be able to eat a greater variety of foods Get rid of my allergies
Have a stronger immune system (e.g., less colds and flues)
No longer use laxatives or stool softeners Be able to exercise again
Have better muscle tone Have less pain
No longer use pain medication No longer use allergy medication
No longer use sleep medication Feel less sleepy in the afternoon Lose weight
Increase my sex drive
Increase my metabolism to burn more fat Increase my flexibility
Reduce my stress Improve my memory Be more mentally focused Have more stable moods Have stronger erections Have fewer headaches
Other:_______________________________ HEALTH RATING:With 1 being “poor” and 10 being “excellent,” on a scale of 1-10, please circle below how you would rate your overall health:
1 2 3 4 5 6 7 8 9 10
WHEN WAS THE LAST TIME YOU FELT REALLY GOOD? ___________________________________ QUESTIONS AND CONCERNS: Please write down the items you would like to discuss with the doctor:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ SIGNATURE:
______________________________________ ______________________________________
HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this Healthcare Facility (More T Clinic Site 1, LLC operating under the service mark More T Clinics). A copy of this signed, dated document (e.g., by email or fax) shall be as effective as the original.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITY IN THE FUTURE.
Date: _________________________________
_______________________________________ __________________________________________ Please print your name Please sign your name
_______________________________________ __________________________________________ Legal Representative (if applicable) Description of Authority for Legal Rep.
Your comments regarding Acknowledgements or Consents: ____________________________________________________
__________________________________________________________________________
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA:
First Name Only Proper Sir Name Other _________________________________________ PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes spouse, children, step parents, grandparents, and any care takers who can have access to this patient s records):
Name: ____________________________________ Relationship: ______________________________ Name: ____________________________________ Relationship: ______________________________ --- 1. I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED AND CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT, AND BILLING INFORMATION VIA:
Cell Phone Confirmation Text Message to my Cell Phone
Home Phone Confirmation Email Confirmation
Work Phone Confirmation Any of the Above
2. I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED TO MY INSURANCE PROVIDER(S):
YES (any) NO (In refusing we will not be allowed to process your insurance claims on your behalf.)
YES, but only the following provider(s): ___________________________________________________ 3. I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS, OR NEW HEALTH INFO on behalf of this Healthcare Facility via:
Phone Message Any of the Above
Text Message None of the above (opt out)
In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health, and this office may receive third party remuneration from affiliated companies of such products/services. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.
--- Office Use Only
As Privacy Officer, I attempted to obtain the patient s (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment _____
I could not communicate with the patient _____ ____________________________________________ The patient refused to sign _____ Signature of Privacy Officer
The patient was unable to sign because _______________________________________________________________________ Other (please describe) _______________________________________________________________________ _______________________________________________________________________ More T Clinics (ver. 27Nov2013)
