Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

(1)

Borland-Groover Clinic

PATIENT GENERATED MEDICAL HISTORY

YOUR PAST MEDICAL HISTORY:

Asthma

COPD Emphysema Blood Transfusion Date: Cancer:

Congestive Heart Failure Coronary Artery Disease

Crohns Disease Ulcerative Colitis Diabetes Mellitus: Type 1 Type 2 Gallstones

GERD

High Blood Pressure Irritable Bowel Syndrome Liver Disease

Pancreatitis

Peptic Ulcer Disease Polyps

Sleep Apnea CPAP machine Y / N Other ALLERGY REACTION ❏ No known allergies Pancreatic Lung Cancer Ovarian Cancer Cancer Stomach Cancer Uterine Cancer Breast Cancer Colon Cancer Ca Esophageal ncer Kidney Cancer Liver Cancer Other Cancer

YOUR SOCIAL HISTORY: Occupation

Working / Retired Tobacco Status: ❏ Former ❏ Never ❏ Current Type:______________ ❏ E-Cigs Qty/day_______ # Yrs__________Age started_____ Stopped_____

Alcohol: Y/N Drinks/Day Social

Former Yr. Stopped

Recreational Drug use: Y / N Type:

Marital Status: M S D W L

Children #: Y/N boys: girls:

Mother: Alive Y/N If no, cause

Father: Alive Y/N If no, cause Sister: Alive Y/N If no, cause Brother: Alive Y/N If no, cause

Other Diseases That Run In The Family:

FAMIL HISTO

YOUR

Y

RY:

Cancer, Breast Cancer, Colon Cancer, Ovary Cancer, Uterus Cancer Colon Polyps Crohn’s Disease Gallstones Liver Disease Pancreatic Dis. Ulcerative Colitis Ulcers P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M P/M RELATIONSHIP AGE

TYPE Paternal/Maternal

YOUR PAST SURGICAL HISTORY:

Appendectomy

Artificial Heart Valve

Artificial Joint (specify______________)

Bowel Obstruction

Neck Artery/Vascular Surgery Pacemaker

ic

Pancreat Surgery

Surgery for Reflux/Hiatal Hernia

Surgery for Ulcers

/ AL PR

MEDIC OBLEMS LIST REASON FOR VISIT

Bowel (repair/resection)

CABG/Heart Bypass Vessels

C Section

Gallbladder removal

Gastric Bypass

Hysterectomy Total Partial

Other

LAST MENSTRUAL PERIOD

Could you be pregnant? Y / N

Directions: Please circle any of the following you have personally had during your life:

Directions: Please circle any of the following

that exists in your family.

Date

AGE

BGC-463 Rev. 04/16 1

Name: DOB: Email:

❏ Adopted

Place Sticker Here

Primary Care Physician: Referring:

Pharmacy: Pharmacy Phone #:

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Borland-Groover Clinic

Drug Name Dosage Start Date Why do you take the medicine?

MEDICATION LOG

NAME:

DOB:

DIRECTIONS: Please list any over the counter or prescribed medications you currently take.

2

(3)

NO YES chills fever lack of energy weight loss

❐

NO YES short of breath frequent cough wheezing

❐

NO YES chest pain extremity swelling palpitations

❐

NO YES nasal congestion sinus infection sore throat

❐

NO YES abdominal pain change in bowel habits constipation diarrhea difficulty swallowing heartburn vomiting blood blood in stool loss of appetite black stool nausea reflux vomiting

❐

NO YES painful urination blood in urine urinary frequency urinary incontinence

❐

NO YES vaginal discharge

❐

NO YES NO YES contact allergy hives itching rash NO YES cold intolerance excessive thirst heat intolerance

❐

headache numbness tremors

sensation of room spinning

❐

NO YES anxiety increased stress

❐

NO YES NO YES NO YES back pain muscle pain joint pain asthma food allergies

altered/weakened immune system seasonal allergies

❐

NO YES bloating

uncontrolled bowel movements gas hemorrhoids yellow skin painful swallowing rectal bleeding

❐

easy bleeding easy bruising

enlarged lymph glands

❐

Borland-Groover Clinic

GI REVIEW OF SYSTEMS - FEMALE

NAME:

DOB:

Directions: Have you had any of the following in the last three months?

(4)

RETURN CHECK, NSF

, CLOSED

ACCOUNTS

Payments made to Borland Gr

oover

Clinic that ar

e not honor

ed by the bank will incur

a r

eturn check fee

of $50.00. If failur

e to pay check and fee within 15 days of r

eceiving r

eturn check notice fr

om Borland

Gr

oover

Clinic account will be turned over

to the State

Attorney’

(5)

Borland

-Groover Clinic

Acknowledgement of Receipt of Notice

& PHI Disclosure Authorization

Pa tie n t’s Fu ll N am e Pa tie n t’s Da te o f B ir th 1. I he re by a uth ori ze Bo rla nd -Gr oo ve r C lin ic to us e or di sc los e pr ot ec te d he alt h inf or m atio n (P H I) ab ou t m e to th e fo llo w in g p er so n( s). Pl ea se w rit e “ N /A ” i n a ny o f t he 3 fi eld s b elo w if n ot po pu la te d w ith th e n am e o f a p er so n: Au th or iz ed In d iv id u al #1 Au th or iz ed In d iv id u al #2 Au th or iz ed In d iv id u al #3 Na m e Ad d re ss Ci ty , S ta te Zi p Ph on e Nu m b er 2. I un de rs ta nd th at th e in fo rm atio n u se d o r d is clo se d m ay b e s ub je ct to r e-di sc los ur e by the pe rs on or c la ss of pe rs ons or fa cil ity re ce ivi ng it, and w oul d the n no longe r be pr ot ec te d by fe de ra l pr iva cy re gul ati ons . 3. Th is au th or iz ati on e xp ires u po n w rit ten n oti ce fro m m e, an d m ay b e rev ok ed at an y t im e. R ev ocat io n m us t b e in wr iti ng a nd su bm itt ed to th e f oll owi ng a dd re ss : P riv ac y Of fic er , 4 80 0 B elf or t R d, Ja ck so nv ill e, F L 32256 . 4. I un de rs ta nd th at m y t re atm en t, p ay m en t, e nro llm en t, o r eli gib ili ty fo r be ne fit s w ill n ot be c ondi tione d on w he the r I sig n t his a uth ori za tio n. 5. NOT IC E : I a ck no w le dg e th at I h av e h ad th e o pp or tu nity to r ev ie w a c op y o f B G C ’s N otic e o f P riv ac y P ra ctic es (“ N oti ce ”). I un de rs ta nd th at I am re sp on sib le to re ad th is N oti ce a nd n oti fy B G C , in w ri tin g, of a ny re qu es t f or re stri cti on s i n t he u se o r dis clo su re o f m y P H I. I u nd er sta nd B G C h as th e r ig ht to re vis e t his N oti ce a t a ny tim e an d w ill p os t a co py o f t he cu rren t N oti ce in th e of fice in a vis ib le lo cat io n at al l ti m es an d o n t hei r w eb sit e at www. bo rla nd gr oo ve r.c om . B G C w ill p ro vid e m e w ith a c op y o f its m os t r ec en t N otic e u po n m y r eq ue st. 6. I un de rs ta nd th e m os t re ce nt ve rs io n o f t his fo rm re pla ce s a ny p re vio us v ers io ns o n f ile in m y B G C h ea lth re co rd . Pr ev io us v er sio ns w ill b e v oid ed a nd PH I r ele as e w ill b e b as ed o n t he cu rren t v er sio n o f t his au th or izat io n. __________________________________________ _______________________________ Si gn atu re o f Pa tie nt Da te o f Pa tie nt Si gn atu re OR ___________________________________ _______________________ __ _______ ______________________ Si gn atu re of Pa tie nt’ s Re pr es en ta tiv e Da te o f R ep re se nta tiv e’ s Si gn atu re De sc rip tio n o f Au th or ity to A ct fo r t he Pa tie nt

A

copy of this completed, signed and dated form must be given to the Individual or