Palo Verde Internal Medicine

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Available Forms

New Patient Paperwork

Name *

Full Name that is on Insurance card (First, Middle, Last):

Birthdate *

Birth Date: xx/xx/xxxx

Sex *

Male

Female

SS#

SS# of Patient

Street Address *

City, State, Zip *

Phone *

Local Phone: (area code) (number)

Cell

Cell Phone: (area code-number)xxx-xxx-xxxx

Email *

eMail Address (if none write NONE)

Employer

Patients Employer:

Spouse

Spouse Name:

Spouse Birthday

Spouse Birthday: xx/xx/xxxx

Emergency Contact

Emergency relationship

Emergency contact relationship:

Emergency Address

Emergency contact Address/City/State

Emergency phone

Emergency Contact Phone: (area code-number) xxx-xxx-xxxx

INSURANCE INFORMATION

Do you have Insurance *

Yes

Ins. Name

Primary Insurance: (Full Name)

Insurance No.

Primary Insurance Number:

Group name or number

Medicare number

Secondary Ins.

Secondary Insurance (Full Name)

Secondary No.

Secondary Insurance Number

Insured Name

Name of Insured (If other than Patient)

Insured Relationship

Insured Relationship to Patient:

Insured DOB

xx/xx/xxxx

REASON FOR VISIT

Why are you here? *

Example, to establish or for specific reason

PAST MEDICAL HISTORY

HAVE YOU HAD ANY OF THE FOLLOWING ILLNESSES? *

check all that apply

Other past medical history

Surgeries *

Other surgeries

Medications

Medications *

List ALL Medications/Dosages/Times per day (if none write NONE)

Medication Allergies *

If none write none

Did you ever smoke? *

Yes

Type

Cigarettes

Packs per Day (____)

Pipe

Cigars

E-Cigarettes

If previous smoker

start date

If previous smoker

quit date

Do you drink alcohol? *

Yes

How many drinks per day?

zero

one

two

three

> four

Review of Systems

General

General Review- Do you feel tired or worn out

Yes

Do you feel depressed a lot of the time

Yes

Have there been any ususual weight gain or loss?

Yes

Skin rashes or itching?

Yes

Unusually dry skin?

Yes

Changes in color or size of skin lesions?

Yes

ENT - Do you have:

Any trouble hearing?

Yes

Ringing or buzzing in your ears?

Yes

Persistent hoarseness?

Yes

A lump in your throat?

Yes

RESPIRATORY - Do you have:

A constant or bothersome cough?

Yes

Difficulty breathing?

Yes

Noticed any wheezing?

Yes

CARDIOVASCULAR- Do you have:

Pain,tightness or pressure in chest

Yes

Swelling in your feet

Yes

Does your heart ever beat fast of irregular

Yes

Do you have cramps in your calf muscle when you walk

Yes

GASTROINTESTINAL- Do you have:

Any trouble swallowing?

Yes

Do you have indigestion or heartburn?

Yes

Do you have frequent diarrhea?

Yes

Have you ever passed bloody or tarry stool?

Yes

Any recent changes in bowel movement?

Yes

GENITOURINARY- Do you have

Burning or pain when you urinate?

Yes

To get up at night frequently to urinate?

Yes

Trouble losing urine when you cough or sneeze?

Yes

Dribbling urine

Yes

Have you ever passed blood in your urine?

Yes

MUSCULOSKELETAL-Do you have

Back pain issues?

Yes

Joint pain or stiffness

Yes

Trouble walking, or issues with your hip or knee joints?

Yes

CENTRAL NERVOUS SYSTEM: Do you have

Frequent or severe headaches?

Yes

Spells of dizziness or faintness?

Yes

Issues with double vision?

Yes

Numbness or tingling in your head, arms, or legs?

Yes

Have trouble remembering recent events

Yes

Are your menstrual periods irregular?

Yes

Women Only

Do you pass clots with your period?

Yes

Women Only

STRUCTED FAMILY HISTORY

Mother

check all that apply

Father

check all that apply

Sister

check all that apply

Brother

check all that apply

Paternal Grandmother- (fathers mother)

check all that apply

Maternal Grandmother- (mothers mother)

check all that apply

Son (s)

check all that apply

Daughter(s)

check all that apply

* Required field