PAST MEDICAL/SURGICAL HISTORY

FORM 004

Please complete the following information by placing a check mark in the appropriate box(es) or by filling in the requested information.

Have you ever been hospitalized?

Yes

No

If yes, in which year?

Have you had any serious injuries and/or broken bones?

Yes

No

If yes, in which year?

Have you ever received a blood transfusion?

Yes

No

Unknown

If yes, in which year?

Have you ever had any surgeries?

Yes

No

If yes, describe:

Have you ever had?

Anxiety, Depression or Mental Illness

Diabetes

High Blood Pressure

High Cholesterol or Triglycerides

Treatment for Alcoholism and/or drug abuse

Immunization History

Have you ever received the following immunizations? Check all that apply

Approximate Year:

Medications

Are you currently taking any prescription and/or non-prescription medications, including vitamins, nutritional supplements, oral contraceptives, pain relievers, diuretics, laxatives, herbal remedies,

and cold medications?

Yes

No

Name of Medication(s):

Allergies

Have you had hives, skin rash, breathing problems, or any other allergic reactions to any medications?

Name of Medication(s):

Describe allergic reaction:

System Review

Please indicate whether you have experienced the following symptoms during recent months, unless otherwise specified, by checking “Yes” or “No” for each question.

Symptoms

Skin rash, sore, excessive bruising or change of a mole?

Yes

No

Excessive thirst or urination?

Yes

No

Significant headaches, seizures, slurred speech, or difficulty moving an arm or leg?

Yes

No

Eye problems such as double or blurred vision, cataracts, or glaucoma?

Yes

No

Diminished hearing, dizziness, hoarseness, or sinus problems?

Yes

No

Experienced cough, shortness of breath, wheezing or asthma?

Yes

No

Coughing up sputum or blood?

Yes

No

Exposed to anyone with tuberculosis or Covid-19?

Yes

No

Blacked out or lost consciousness?

Yes

No

Chest pain or pressure, rapid or irregular heartbeats or known difficulty with heart value?

Yes

No

Difficulty with swallowing, heartburn, nausea, vomiting or stomach trouble?

Yes

No

Significant problems with constipation, diarrhea, blood/changes in bowel movements?

Yes

No

Difficulty starting your urinary stream, completely emptying your bladder or leaking urine?

Yes

No

Feel you are at risk for HIV/AIDS?

Yes

No

Experiencing an unusually stressful situation?

Yes

No

These questions are only for female patients. Please answer to help us provide the best care for you.

Date of onset of your last menstrual period

Month

Day

Year

Number of:

Pregnancies:

Live Birth(s):

Miscarriage(s)/Abortion

Emergency Contact

Please list your primary emergency contact person as well as their contact info, in case we need to contact them on your behalf in case of an emergency during your visit at the clinic.

Primary Emergency Contact Name:

Relationship to Patient:

Home Phone:

Cell Phone:

Work Phone:

Authorization

I certify that I have read and understand the information on this form and have answered all of the questions accurately and to the best of my knowledge. I understand that providing incomplete information can be dangerous to my health. I authorize my insurance benefits be paid directly to CSBS physician. I understand that I am financially responsible for all services rendered on my behalf or on the behalf of my dependents, and for any balance not paid by my insurance policy. I also authorize CSBS to release information required to process my claims.

Signature of Patient

Signature field is empty.

Notice of privacy practices acknowledgement form

First name

Last name

Client ID#

Facility/Site/Program: Excellent Comprehensive Care

I have received a copy of the PA Notice of Privacy Practices Form PA 150-741, 09/20.

Signature of Patient

Signature field is empty.

If the individual has a representative with legal authority to make health care decisions on the individual’s behalf, the notice must be given to and acknowledgment obtained from the representative. If the individual or representative did not sign above, staff must document when and how the notice was given to the individual, why the acknowledgement could not be obtained, and the efforts that were made to obtain it.

Face to Face Meeting

Mailing

Emailing

Other

Notice of Privacy Practices given to the individual on:

Reason Individual or Representative did not sign this form:

Individual or Representative chose not to sign

Individual or Representative did not respond after more than one attempt

Email receipt verification

Other

Good Faith Efforts: The following good faith efforts were made to obtain the individual’s or representatives signature. Please document with detail (e.g., date(s), time(s), individuals spoken to and outcome of attempts) the efforts that were made to obtain the signature, More than one attempt must have been made.

Face to Face Presentation(s)

Phone