Adult New Patient Form - Mountain View Medical Center
Acknowledgement and Consent I understand that Mountain View Medical Center (referred to below as “This Practice”) will use and disclose health information about me. I understand that my health information may include information both created and received by This Practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: Make decisions about and plan for my care and treatment; Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; Determine my eligibility for health plan or insurance coverage and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and Perform various office, administrative, and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care. I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in the waiting/reception area. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices. By: ______________________________________ Patient or Guardian Signature Date: _______________________ 1909 Mountain View Lane, #200, Forest Grove, Oregon 97116 | 4660 NE Belknap Court #119, Hillsboro, Oregon 97124 Phone (503) 359-4773 | Fax (503) 359-3809 Patient’s Responsibility for Payment As a service to our patients, Mountain View Medical Center (MVMC), will submit charges for medical treatment to the patient’s insurance company. However, the patient is primarily responsible for paying any and all medical expenses incurred at the clinic. If you do not have any medical insurance, you will be responsible for the bill at the time of service. Monthly statements will be sent when there is a patient balance and payment is expected on a regular basis. MVMC may attempt to verify in advance that the patient’s insurance company will pay for specific medical procedures. Occasionally, even though coverage was verified before the medical services were provided, the insurance company denies the claim. If the insurance company denies payment or will only pay a portion of the medical bill, the patient is responsible for payment of the account balance. Likewise, if the patient has not met his or her deductible under a given insurance plan, the patient will be responsible for the amount of the deductible in addition to whatever amounts the insurance company does not pay. If the patient has an insurance company that requires co-payment, the co-payment must be paid at the time of the appointment or a $10 fee will be added in addition to the co-payment. If the patient has health insurance coverage through the Oregon Medical Assistance Program (Welfare) and wishes our clinic to provide immunizations, we do not participate in their immunization program and any expenses incurred as a result of immunizations being provided through our clinic will be billed directly to the patient or the parent or guardian if the patient is a minor. If the patient has a worker’s compensation claim, MVMC will submit the claim information to the employer’s insurance carrier. The patient must provide MVMC with the name of the insurance carrier, the date of injury, and, if available, the claim number and a copy of the 801 form. Patients must keep track of their own mileage and prescription costs for reimbursement by the insurance provider. A fee will be charged to you if you request the clinic compile this information. If the patient is involved in a motor vehicle or liability accident, the patient is responsible for paying all medical costs, even if there is a pending lawsuit. Contractual Agreement to Pay Medical Expenses I understand that I am personally responsible for all medical expenses incurred at MVMC for medical care and treatment. I agree to pay all medical expenses within 30 days of the date I am billed for those expenses, unless other arrangements have been made with MVMC. If my account balance is sent to a collection agency for non-payment by me, I understand that a penalty of $150 will be assessed in addition to the account balance. If I do have insurance, I authorize release of all my medical information to my insurance company and I authorize payment of all medical benefits by my insurance company to MVMC. Signature: ______________________________________ Date: ______________________ Patient or Guardian Signature 1909 Mountain View Lane, #200, Forest Grove, Oregon 97116 | 4660 NE Belknap Court #119, Hillsboro, Oregon 97124 Phone (503) 359-4773 | Fax (503) 359-3809 New Patient Health History NAME: ___________________________________________________________BIRTHDATE: _____________________________________ TODAY’S DATE: _____________________________ REFERRED TO MVMC BY: _____________________________________________ DATE OF LAST PHYSICAL EXAM: ____________________________________________________________________________________ NAME OF PREVIOUS PROVIDER: ___________________________________________________________________________________ MEDICATIONS SEE ATTACHED LIST List any medications you are taking: Dosage How many times per day? ALLERGIES List any medication allergies you have: Reaction RISK FACTORS TOBACCO USE Do you currently use tobacco? YES NO Have you ever used tobacco? YES NO When did you start? ___________________ What type of tobacco do you use? __________________________ Ha How much do you smoke per day? __________________ Have you ever been advised to cut down? YES NO Have you been exposed to second hand smoke? YES NO DRUG USE Do you use recreational drugs? YES NO What type of recreational drugs? ____________________ Have you ever used IV (injectable) drugs? YES NO ALCOHOL USE Do you drink alcohol? YES NO What type of alcohol? _______________ Drinks per day? _________ Do you feel the need to cut down? YES NO Have you ever been advised to cut down? YES NO Have you ever felt guilty regarding your drinking? YES NO Do you ever need an eye opener in the morning? YES NO EXERCISE Do you exercise? YES NO How many times per week? ___________ What type of exercise? _____________________________________________ OTHER How many cups of coffee/ caffeine do you drink per day? ___________ What percentage of the time do you wear your seatbelt? ___________ How many hours of sun exposure do you get per day? ______________ 1909 Mountain View Lane, #200, Forest Grove, Oregon 97116 | 4660 NE Belknap Court #119, Hillsboro, Oregon 97124 Phone (503) 359-4773 | Fax (503) 359-3809 REVIEW OF SYSTEMS - Check all symptoms you currently have General Depression Dizziness Fainting Forgetfulness Headache Loss of sleep Sweats Weight Loss Genitourinary Blood in urine Frequent urination Lack of bladder control Painful urination Gastrointestinal Bowel Changes Poor appetite Rectal Bleeding Stomach pain Vomiting blood Eye, Ear, Nose, Throat Bleeding gums Blurred vision Difficulty swallowing Hoarseness Loss of hearing Nosebleeds Muscle/ Joint/ Bone Pain Persistent cough What location? Ringing ears __________________________ Seasonal allergies Sinus problems Respiratory Cough CPAP use Oxygen use Shortness of breath Wheezing Cardiovascular Chest pain High blood pressure Irregular heart beat Swelling of ankles Skin Bruise easily Change in moles Hives Itching Rash PAST MEDICAL HISTORY- Check conditions that you have had in the past AIDS/ HIV Alcoholism Anemia Anorexia/Bulimia Arthritis Asthma Anxiety Bleeding Disorder Blood Transfusion Breast Lump Cancer ________________ Cataracts Chemical Dependency Chicken Pox- Year? __________ Depression Diabetes Emphysema/COPD Epilepsy/Seizures Glaucoma Goiter Gout Heart attack Hepatitis Hernia Herpes High blood pressure High cholesterol/ lipids Kidney Disease Liver Disease Migraine Headaches Multiple Sclerosis Pacemaker Pneumonia Polio Prostate problem Rheumatic Fever Suicide Attempt Thyroid Problems Tuberculosis Sexually transmitted infections Skin problems Stomach ulcers Stroke Other: ______________________ _______________________ ______________________ SURGICAL HISTORY SEE ATTACHED LIST Please list all past surgeries: Doctor or location: Date FAMILY HISTORY- List blood relatives with the following problems including Mother, Father, Sister, and Brother Blood disorder _______________________________ Kidney Disease _______________________________ Skin Disease ___________________________ Cancer______________________________________ Mental Illness _________________________________ Stroke _________________________________ Diabetes ____________________________________ Neurological Disease ___________________________ Thyroid Disease ________________________ Heart Attack ____________________________ Growth / Developmental Disorder Tuberculosis____________________________ High blood pressure _____________________ _____________________________________ Other _________________________________ SOCIAL HISTORY Single Committed Relationship Divorced Married Please list children’s names: __________________________________________________ Children’s birth years: ___________________________ Name of Employer: _____________________________ Job Title: ___________________________ What is your highest level of education? ______________________________________________________________ What is your marital status? 1909 Mountain View Lane, #200, Forest Grove, Oregon 97116 | 4660 NE Belknap Court #119, Hillsboro, Oregon 97124 Phone (503) 359-4773 | Fax (503) 359-3809 GYNECOLOGY HISTORY- FEMALE ONLY At what age did you start your periods? ____________ Do you still have periods? YES NO Regular periods? YES NO How much time between your periods? ______________ How is your menstrual flow? Light Moderate Heavy How long do they last? __________________________ Any bleeding between periods? YES NO Year of menopause:______________________________ Do you get painful periods? YES NO First day of your last period: ____________________ Are you currently in a sexual relationship? YES NO Have you ever been in a sexual relationship? YES NO What type of contraception (birth control) do you use? _________________________________ # of times have you been pregnant? _____ # of living children? _____ # of premature births? _____ # of abortions? _____ # of miscarriages? _____ Do you desire pregnancy now? YES NO Do you desire pregnancy in the future? YES NO Do you have a history of the following: Abnormal pap smear tests Cancer of the breast, cervix, ovaries, uterus Leakage of urine Ovarian cysts Uterine fibroids 1909 Mountain View Lane, #200, Forest Grove, Oregon 97116 | 4660 NE Belknap Court #119, Hillsboro, Oregon 97124 Phone (503) 359-4773 | Fax (503) 359-3809
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