Patient Form

Please fill in the applicable sections of the form below.

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Patient Contact Information

First name:

Last name:

Middle initial:

Date of birth (MM/DD/YYYY):

SSN:

Sex:

Address:

City:

State:

Zip code:

Primary phone: (home / cell)

Secondary phone:

Email:

How did you hear about us?

Referring provider

Pharmacy

Emergency Contact Information

Name:

Relationship:

Phone:

Notice of Privacy Practice Acknowledgement

I have read and understand the Notice of Privacy Practices containing a complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time. I understand that I may request a copy of the Notice of Privacy Practices as well as request, in writing, that you restrict my private information as used or disclosed to carry out treatment, payment, or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if they do, then they are bound to abide by such restrictions.

Signature:

Date:

Allergies

Do you carry an EpiPen / epinephrine injector for allergies?

1. Medication / Substance - (what are you are allergic to)

Reaction - (for example - anaphylaxis, hives, rash, etc.)

When did this first occur?

2. Medication / Substance - (what are you are allergic to)

Reaction - (for example - anaphylaxis, hives, rash, etc.)

When did this first occur?

3. Medication / Substance - (what are you are allergic to)

Reaction - (for example - anaphylaxis, hives, rash, etc.)

When did this first occur?

4. Medication / Substance - (what are you are allergic to)

Reaction - (for example - anaphylaxis, hives, rash, etc.)

When did this first occur?

Medication List

1. Medication & Strength
(Example: Aspirin: 81mg)

Dose
(Example: 1 tablet)

Route
(Example: by mouth)

Frequency:
(Example: Once a day)

Indication:
(Example: Heart health)

2. Medication & Strength

Dose

Route

Frequency

Indication:

3. Medication & Strength

Dose

Route

Frequency

Indication:

4. Medication & Strength

Dose

Route

Frequency

Indication:

5. Medication & Strength

Dose

Route

Frequency

Indication:

Cardiovascular History

Have you ever had any of the following?

Heart attack (myocardial infarction):

Yes

Coronary angiogram or balloon/stent procedure:

Yes

(If yes, which?)

Heart surgery:

Yes

(If yes, what kind?)

Echocardiogram (ultrasound of the heart):

Yes

Surgery on arteries:

Yes

Aneurysm:

Yes

(If yes, where?)

Carotid Doppler (ultrasound of arteries in neck):

Yes

Arterial Doppler (leg circulation test):

Yes

Past Medical History

Do you have / or have had any of the following?

Diabetes (Type 1 or Type 2 ?):

Yes

Coronary artery disease (CAD):

Yes

Heart attack (myocardial infarction):

Yes

Angina:

Yes

Stroke:

Yes

Hypertension (high blood pressure):

Yes

Varicose veins:

Yes

COPD:

Yes

Asthma:

Yes

Anemia:

Yes

Cancer:

Yes

Cancer - what kind(s)?

HIV+:

Yes

Atrial fibrillation (A-fib):

Yes

Bleeding disorder:

Yes

Describe:

Kidney disease:

Yes

Describe:

Peptic (stomach) ulcers:

Yes

Cirrhosis:

Yes

GERD / Acid Reflux:

Yes

Sleep apnea:

Yes

Thyroid problems:

Yes

Describe:

Please list any and all other conditions with which you have been diagnosed (for example - anything you have been told to take medication or other treatment for) and when you were diagnosed (approximate is ok).

Please list any and all surgeries you have had and when you had them (approximate is ok).

Social History

Relationship status

Do you have children?

If yes, how many, sex?

Tobacco / Nicotine / Drug

Type? - Cigarettes, Chew, Vape/e-cigarette, other

Alcohol use

How much? Drinks per day / week / month / year

Caffeine

What kind(s)? - Coffee, Tea, Soda, Energy drinks, other:

Employment

Occupation

Do you sit, stand, walk, or do manual labor?

How much physical activity / exercise do you do?

What kind of activity?

Family History

Please list siblings and children if they have medical problems:

Mother

Alive / Deceased / Unknown

Age

Problems

Father

Alive / Deceased / Unknown

Age

Problems

Male / Female

Alive / Deceased / Unknown

Age

Problems

Male / Female

Alive / Deceased / Unknown

Age

Problems

Male / Female

Alive / Deceased / Unknown

Age

Problems

Has anyone in your family ever had any of the following?

If yes, please specify who:

Heart attack (myocardial infarction)

Stroke

Coronary artery disease (CAD)

Hypertension (high blood pressure)

Abdominal aortic aneurysm

High Cholesterol

Diabetes (Type 1 or Type 2?)

Review of Systems

Have you had any of the following in the last 3 months?

Chest pain

Diaphoresis (sweating)

Edema (swelling in ankles/legs)

Weight loss

Dizziness

Memory loss

Orthopnea (difficulty breathing while laying down)

Weight gain

Seizures

Palpitations

Fever

Snoring / sleep apnea

Erectile dysfunction

Goiter (enlarged thyroid)

Syncope (fainting)

Claudication (pain in legs when walking)

Dyspnea on exertion (shortness of breath with exertion)

Vein Screening Assessment

Patient Information

Patient's Name

Date

Primary Insurance

Secondary Insurance

Sex:

Male

Female

Date of birth:

How did you hear about us?

History

Have you ever had varicose veins or bulging veins?

Yes

Signs and Symptoms

Do you experience any of the following in your legs or ankles?

Leg pain, aching or cramping
Burning or itching of the skin
Leg or ankle swelling, especially at the end of the day
"Heavy" feeling in legs
Varicose veins
Skin discoloration or texture changes, such as above the inner ankle
Open wounds or sores, such as above the inner ankle
Restless legs

Please explain:

Risk Factors

Has anyone in your family ever had varicose veins?

Yes

Have you had any treatments or procedures for vein problems?

Yes

Do you sit or stand for long periods of time, such as at work?

Yes

Do you frequently engage in heavy lifting?

Yes

Have you ever had varicose veins or bulging veins?

Yes

Additional Notes:

Insurance

Patient name:

Date of birth:

Insurance:

You are receiving this notice because your insurance may not pay for all the services that you receive during your office visit.

Please read this notice, so you can make an informed decision about your care.

Yes: I want to receive these services. If my insurance carrier denies payment, I am completely responsible for payment in full.

No: I have decided not to receive these services.

By electronically signing this notice you agree to take financial responsibility for the cost of the supplies and services performed if your insurance company denies coverage for the listed items.

Patient name:

Date:

MEMORIAL HERMANN INFORMATION EXCHANGE

MEMORIAL HERMANN INFORMATION EXCHANGE "MHiE" PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose

The MHiE is a health information exchange network developed by Memorial Hermann Health System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members are able to share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for treatment, payment and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.

Instructions

If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.

Patient name: (First, Last, Middle)

Date of Birth:

Information that will be Disclosed; Purpose of the Consent for Disclosure

I, hereby consent to the disclosure of my medical health and encounter information by any and all Memorial Hermann Health System providers (collectively the "Provider") to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.

I HEREBY SPECIFICALLY AUTHORIZE PROVIDER TO RELEASE ALL TYPES AND CATEGORIES OF PROTECTED HEALTH INFORMATION TO OTHER HEALTHCARE PROVIDERS THAT PARTICIPATE IN THE MHiE FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATION PURPOSES, [INCLUDING BUT NOT LIMITED TO, YOUR ALCOHOL AND TREATMENT RECORDS, YOUR DRUG ABUSE TREATMENT RECORDS, YOUR MENTAL HEALTH RECORDS, AND YOUR HIV/ACQUIRED IMMUNE DEFICIENCY SYNDROME RECORDS, AS APPLICABLE).

No Conditions

This Consent is voluntary. We will not condition your treatment on receiving this Consent. HOWEVER, IF YOU DO NOT SIGN [AND INITIAL} THIS CONSENT, WHERE REQUIRED. YOU CANNOT PARTICIPATE IN THE MHIE.

Effect of Granting this Consent

This Consent permits all MHiE Exchange Members to access your health information. Exchange Members of the MHiE are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Term and Revocation

This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHiE notice of revocation. The MHiE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this Consent will not affect any action we took in reliance on this Consent before we received your notice of revocation. Revocation of this Consent will also have no effect on your personal health information made available to Exchange Members during the time frame in which your Consent was active.

Individual's Signature

I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am confirming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.

Patient's electronic signature:

Date:

If this Consent is signed by a personal representative on behalf of the individual, complete the following:

Personal representative's name:

Relationship to individual:

MEMORIAL HERMANN
Information Exchange Patient
Consent For The Use And Disclosure
15142 (2/17)

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