This form should be filled out completely

 

Personal Information

First Name
Middle Initial

Last Name

Gender
Date of birth
Cell Phone Number
Home Phone Number
Work Phone Number
Address LIne 1
City
State
Zip Code
Email Address
Have you been known by another name?
How Did You Find Our Office?

Insurance Information

  
Office Visit Copay
Primary Ins Carrier Name
   
Subscriber Name
Subscriber Date of Birth 
Subscriber’s Contract Number 
Group Name or Number
Subscriber’s Employer
Subscriber Relationship to Patient  Self     Spouse     Dependent
 
Secondary Insurance Carrier (if applicable)
Subscriber Name
Subscriber Date of Birth 
Subscriber’s Contract Number
Group Name or Number
Subscriber’s Employer
 
Subscriber Relationship to Patient  Self     Spouse     Dependent
Responsible Party Name (if different from patient)
Name of person responsible for bill if other than yourself or subscriber, or if address if different
Emergency Contact Name
Emergency Contact Phone
Referred By 
Referred Phone Number
 
Who is your appointment with today??
  


 

Pertinent Medical History and Intake Form

 
Past Medical History: (please select all that apply)  
Anxiety Hepatitis
Arthritis Hypertension
Artificial Joints HIV/AIDS
Asthma Hypercholesterolemia
Atrial fibrillation Hyperthyroidism
 
BPH Hypothyroidism 
Bone Marrow  Leukemia 
Transplantation Lung Cancer
Breast Cancer Lymphoma 
Colon Cancer Pacemaker 
COPD Prostate Cancer
 
Coronary Artery Disease Radiation Treatment
Depression Seizures 
Diabetes Stroke 
End Stage Renal Disease Valve Replacement
GERD None 
Hearing Loss Other: (type below)
 
Past Surgical History: (please check all that apply)  
Appendix Removed Kidney Biopsy
Bladder Removed Kidney Removed (Right, Left)
Mastectomy (Right, Left, Bilateral) Kidney Stone Removal
Lumpectomy (Right, Left, Bilateral) Kidney Transplant
Breast Biopsy (Right, Left, Bilateral) Ovaries Removed: Endometriosis
  
Breast Reduction Ovaries Removed: Cyst
Breast Implants  Ovaries Removed: Ovarian Cancer
Colectomy: Colon Cancer Resection Prostate Removed: Prostate Cancer
Colectomy: Diverticulitis Colectomy: IBD Prostate Biopsy 
Gallbladder Removed TURP 
Coronary Artery Bypass Skin Biopsy
 
PTCA Basal Cell Cancer Surgery
Mechanical Valve Replacement Squamous Cell Carcinoma Surgery
Biological Valve Replacement Melanoma Surgery
Heart Transplant Spleen Removed
Joint Replacement, Knee (Right, Left, Bilateral) Testicles Removed (Right, Left, Bilateral)
Joint Replacement, Hip (Right, Left, Bilateral) Hysterectomy: Fibroids
 
Joint Replacement within last 2 years Hysterectomy: Uterine Cancer
None Other: (type below)
  
Skin Disease History: (please check all that apply)  
Acne Hay Fever/Allergies
Actinic Keratoses Melanoma
Asthma Poison Ivy
Basal Cell Skin Cancer Precancerous Moles
Blistering Sunburns Psoriasis 
   
Dry Skin Squamous Cell Skin
Eczema Cancer 
Flaking or Itchy Scalp  
None  Other: (type below)
 
Do you wear Sunscreen?                                  If yes, what SPF?   
Do you tan in a tanning salon?                           
Do you have a family history of Melanoma?       If yes, which relative(s)? 
Cautions: (please check all that apply)  
Have you ever had difficulty stopping bleeding? 
Do you have problems with healing or scarring? 
  
Do you require antibiotics prior to a surgical procedure? 
Have you had an artificial joint replacement? 
 
If yes, when and what body locations?
Do you have an artificial heart valve? 
Do you have a pacemaker? 
 
Do you have a defibrillator? 
Are you pregnant or currently trying to get pregnant? 
 
Medications: (enter all medications, oral and topical)
 
  
Allergies: (please enter all allergies to medications and other allergies if known)
 
Social History: (please ckeck all that apply)

Currently Smokes     Has Smoked in the Past     Drug Use     None 

Other: 
 
Alcohol Use:  (ONLY SELECT ONE)  
Less Than 1 Drink Per Day 1-2 Drinks Per Day 
3 or More Drinks Per Day  None: 
      
Review of Systems: Are you currently experiencing any of the following? (please circle yes or no for the following)
  
Abdominal Pain                      Cough                             Night Sweats                      
Anxiety                                  Depression                      Rash                                  
Bleeding Problems                 Fever or Chills                 Seizures                            
Bloody Stool                          Headaches                      Shortness of Breath            
Bloody Urine                          Hay Fever                       Sore Throat                        
Blurry Vision                          Joint Aches                     Thyroid Problems                
Changing Mole                       Muscle Weakness            Unintentional Weight Loss   
Chest Pain                             Neck Stiffness                 Wheezing                           
Other: (type below)
    

   
  

Briefly- Main Reason for visit:    
Rash Acne/Pimples Fungus
Concerns about new or changing Growths/moles Psoriasis Discoloration
Cosmetic History of Skin Cancer- Skin Exam Wart
Other:
    


You will be asked to sign this form upon your arrival.

Your signature is an acknowledgement that you are aware of the posted “Notices of Privacy Practices” of Associated Dermatologists of West Bloomfield, Commerce & Novi and that a copy is available upon request.  

X ____________________________________________________________________________ 

Signature of Patient (or parent/ guardian if the patient is a minor) 
_______/_______/_________
          Date signed

  

We are asked to collect certain demographics from all patients. Please answer the following: Again, If you are uncomfortable answering this question, you may choose : “I choose not to answer this question” How would you describe the race of the patient? (Please mark and “X” in the box adjacent to the answer that best describes this.)
Race:  (ONLY SELECT ONE)
White          Black or African American          Native American including Alaska Native American                             Native Hawaiian or other Pacific Islander         Asian       Two or more races    I choose not to answer this question 
Ethnicity: (ONLY SELECT ONE)  
Hispanic/Latino      Non Hispanic     I choose not to answer this question Preferred Language :  
Preferred Language :

 
 

Primary Care Physician (Family Doctor, Pediatrician, Internal Medicine Doctor)
Name:
Phone:
City Location of Practice:

 
  

Pharmacy (indicate local or mail order)

Pharmacy Name:        Local         Mail order 
Pharmacy Phone:
Address or Cross Street / City:
Other Pharmacy Name (if using both local and mail order) 


 

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I authorize my physician and or administrative and clinical staff to disclose the following information to
Myself only
My spouse or significant other (specify name) 
My parent(s) (specify name) 
Other (specify name & relation) 
Would you like access to your test results on a secure site with a user name and password unique to you? YES         NO

If so, please tell receptionist and he/she will set this up for you. It can be done anytime, so if you decide later that you are interested, Please let us know.

Information to be disclosed: 

All information              Lab results                  Diagnosis                 Pathology Results             Medications
Dates of service:         Other:

My preferred method of contact is:
Land line (home phone)      Cell phone 
Work phone   Email

Please check the box below regarding the office staff or physician leaving information or confirming appointments on my answering machine, voice mail or with my answering service.

No, I do not want any information left on any message systems
 Yes, I give permission for only non-medical messages and appointment reminders to be left on my message system
Yes, I give my permission for medical information, non medical messages and appointment reminders to be left on my message system
 

You will be asked to sign this form upon your arrival.


This authorization shall be in force and effective until revoked, at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Privacy officer at the address below. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by the federal HIPAA Privacy Rule or state law.

Signature: (parent if minor) ___________________________________________________________________

Date: __________________ Patient’s Name (please print): ______________________________________________________

 


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