Pre Registration Information Sheet Page 1

 
You can print this page and fill out the information at home to save you time on your first visit!

For best results: Clike the "printable view button" at the bottom of the last page. Then print out the 3 pages at once.

MEDICAL HISTORY Pg. 1

Name ______________________ Date ____________
Allergies _________
Past Medical History & Review of Systems DOB ____________

Please circle if you have had problems with or are presently complaining of any of the following:
High Blood Pressure / Pneumonia / Unexplained weight gain/loss / Arthritis / Diabetes / Persistent cough / Hemorrhoids / Low back pain / Cancer / T.B. / Gallbladder Disease / Skin Disorders / Heart Disease / Hay Fever / Colitis / Blood Disorders / Chest pain / Chest Tightness / Abdominal Discomfort / Hepatitis or Jaundice / Venereal Disease / Indigestion / Thyroid Disease / Anxiety / Shortness of Breath / Nausea / Head or neck Pain or radiation / Depression / Swollen ankles / Vomiting / Headache / Anemia / Palpitations / Constipation / Kidney Disease / Alcohol Abuse / Lightheadedness / Diarrhea / Kidney Stones / Drug Abuse / Rheumatic Fever / Blood in Stool / Difficulty Urinating/ Gout / Asthma / Ulcers / Frequent Urination / Bronchitis / Change in Bowel Habits

Last Mammography ____________________ Last Pap _____________ Last Tetanus Shot ________
Last Flexible Sigmoidoscope______________

Surgical History

Surgery_____________ Date_________ Surgery_____________ Date_________ Surgery_____________ Date_________ Surgery_____________ Date_________

Gynecologic and Obstetric History

OB/GYN Doctor ___________________________
Age at onset of periods__________ Frequency _________ Length of period ______________
Pregnancies: __________________ Births ____________ Miscarriages ________________
Complications of Pregnancies__________________________________________________
Contraceptive Plan __________________________________________________________
Prolonged or abnormal bleeding _______No ________Yes
Leakage of urine _______No ________Yes
Pelvic Pain _______No ________Yes
Abnormal discharge _______No ________Yes
History of abnormal Pap smear _______No ________Yes

Referred by ___________________ Insurance Book ___ Friend ____ Family ____
(Name)


Pre Registration Information Page 2

 
You can print this page and fill out the information at home to save you time on your first visit!

For best results: Clike the "printable view button" at the bottom of the last page. Then print out the 3 pages at once.


MEDICAL HISTORY Pg. 2

NAME DOB:
SOCIAL HISTORY:
Smoke: How much per day? How long? When stopped:
Alcohol: Type? How much per day?
Coffee/Tea: How many cups per day? Other caffeine?
Do you have an allergy to? Dust Animals Shellfish Environment Drugs
Name of Drugs Type of reaction

FAMILY HISTORY:
Please circle if any family member has had or is presently experiencing any of the following:

Diabetes / High Blood Pressure / Migraine / Cancer / Elevated Cholesterol or Triglycerides / TB / Convulsions / Kidney Disease / Sickle Cell / Allergies / Blood Disorders / Eye Problems / Asthma / Mental Retardation / Dental Problems / Heart Disease / SIDS / Eczema/ Skin Problems / Stroke / Drug or Alcohol Addiction / Emotional Disorder / Other

PREVENTION
Do you use alcohol, tobacco, drugs or substances? Yes No
Do you wear a seatbelt? Yes No
Do you wear a bike helmet? Yes No
Do you have guns in the home? Yes No
Are you at risk for AIDS? Yes No
Have you ever worked with chemicals, paints, asbestos
or other hazardous material? Yes No
Are you in a relationship in which you have been
physically hurt (e.g. slapped, kicked, punched,
bruised by your partner? Yes No
Do you ever feel afraid of your partner? Yes No
Do you have a living will? Yes No
Do you have a donor card? Yes No
Do you do a breast self exam? Yes No


CURRENT MEDICATIONS Start Date Ordered by


Pre Registration Page 3

 
You can print this page and fill out the information at home to save you time on your first visit!

For best results: Clike the "printable view button" at the bottom of the last page. Then print out the 3 pages at once.

For best results: Clike the "printable view button" at the bottom of the last page. Then print out the 3 pages at once.


PATIENT REGISTRATION Pg. 3

Name__________________________________________________Date of Birth___________ M_ F_
(Last First MI)
Address________________________________________________________________________________ Marital Status: S M W SP Div (Please circle one) SS# _______________ Home Phone #____________
Work Phone # _______________ Emergency Contact/Phone#:_________________________________
Spouse/Parent/Guardian______________________________________ Phone #__________________
Spouse/Parent Address ________________________________________________________________
Name of Children: _______________________________________________________________________
Patient Employer ________________________________________________________________________
Employer Address _____________________________________________________________________
______________________________________________ Phone #_________________________________
Insured Person (if not patient)____________________________ SS# ____________________________
Address_________________________________________ Date of Birth __________________________
Relationship to Patient____________________________________________________________________
Employer Name ____________________________ Phone #______________________________
Primary Insurance_____________________________________________________________
Insurance Co. Address___________________________________________________________
ID # _______________________Group#____________ Phone #____________________
Secondary Insurance ________________________________________________________
ID #______________________Group #_____________________Phone #______________________
AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFIT
 
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION TO MY INSURER CONCERNING PROCESSING OF CLAIMS, DIAGNOSIS AND TREATMENT.
I HEREBY AUTHORIZE DR.GROSS TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED BY HIS ORDER. I REQUEST THAT PAYMENT FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO DR. GROSS
IF I HAVE MEDICARE INSURANCE, I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS BE MADE ON MY BEHALF TO SCOTT L. GROSS MD, FOR SERVICES FURNISHED TO ME BY THE PROVIDER. I ALSO AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.{NOTE: THE SIGNATURE AUTHORIZATIONS RETAINED IN THE PROVIDER’S FILE WILL BE PERIODICALLY INSPECTED BY THE MEDICARE CARRIER DURING OUR NORMAL AUDITING PROCESS.}
I CERTIFY THAT THE INFORMATION I HAVE REPORTED WITH REGARD TO MY INSURANCE COVERAGE IS CORRECT. I FURTHER CERTIFY THAT (IF REQUIRED BY MY INSURANCE) I HAVE CHOSEN DR. GROSS TO BE MY PRIMARY CARE PROVIDER, OR HAVE OBTAINED THE APPROPRIATE PRIOR AUTHORIZATION (OR REFERRAL) TO PERMIT HIM TO TREAT ME. IF I HAVE NOT PROVIDED THE ABOVE (OR IF MY INSURANCE DENIES RECEIVING THE ABOVE), I AGREE TO BE PERSONALLY RESPONSIBLE FOR ANY AND ALL CHARGES INCURRED DURING MY TREATMENT.
I UNDERSTAND THAT A SERVICE CHARGE OF 1.5% PER MONTH, 18% PER YEAR WILL BE ADDED TO ANY BALANCE DUE MORE THAN 30 DAYS BEYOND DATE OF TREATMENT.
I UNDERSTAND THAT IF I SUSPEND OR TERMINATE TREATMENT ANY PROFESSIONAL SERVICE FEES WILL BE IMMEDIATELY DUE AND PAYABLE. IF IT IS NECESSARY FOR DR GROSS’ OFFICE TO TAKE LEGAL ACTION IN ORDR TO OBTAIN PAYMENT FOR SERVICES RENDERED TO ME, I WILL BE RESOPONSIBLE FOR COLLECTION AND ATTORNEY FEES ASSOCIATED WITH THE COLLECTION OF OUTSTANDING MONIES DUE AND PAYABLE.
I PERMIT A COPY OF THIS INFORMATION TO BE USED IN PLACE OF THE ORIGINAL. THIS AUTHORIZATION MAY BE REVOKED BY EITHER ME OR MY INSURANCE COMPANY AT ANY TIME IN WRITING.
 
SIGNATURE: ____________________________________________  DATE: ____________________
 
      I CERTIFY THAT I HAVE RECEIVED A COPY OF THE OFFICE’S PRIVACY NOTICE AND HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS REGARDING THAT POLICY
 
SIGNATURE: ____________________________________________ DATE: ____________________
 
      NEW YORK STATE PUBLIC HEALTH LAW REQURES THAT AN OFFER OF HIV RELATED TESTING BE MADE TO ALL PERSONS BETWEEN THE AGES OF 13 AND 64. HIV IS A VIRUS THAT CAUSES AIDS AND IS PASSED FROM ONE PERSON TO ANOTHER DURING UNPROTECTED SEX WITH SOMEONE WHO HAS HIV. HIV CAN ALSO BE PASSED THOUGH CONTACT WITH BLOOD OR BLOOD PRODUCTS (SUCH AS SHARING NEEDLES, PIERCIINGS, TATTOOING, INJECTING DRUGS). IF YOUR TEST IS NEGATIVE YOU CAN LEARN HOW TO PROTECT YOURSELF FROM BEING INFECTED IN THE FUTURE. IF IT IS POSITIVE YOU CAN TAKE STEPS TO PREVENT PASSING THE VIRUS TO OTHERS, AND YOU CAN RECEIVE TREATMENT FOR HIV.
____    YES, I WOULD LIKE TO SPEAK TO SOMEONE ABOUT HIV TESTING
____    NO, I WOULD NOT WISH TO HAVE HIV TESTING DONE
 
SIGNATURE: ____________________________________________  DATE: ____________________

 



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