Patient Form

PATIENT DEMOGRAPHICS

First Name

Last Name

Date of Birth

Gender

Female Male

Marital Status

Single Married Divorced Widow

Enter Last 4 digits of SSN:

Occupation

Address

Apt #

City

State

Zip

Phone #

Secondary Phone #

ADVANCED DIRECTIVES

Do you have a living will?

Yes No

Do you have a power of attorney?

Yes No

Do Not Resuscitate (DNR) order in place?

Yes No

EMERGENCY CONTACT

Emergency Contact Name

Relationship

Primary Phone #

Secondary Phone #

PRIMARY CARE PROVIDER

Primary Care Provider’s Name

Phone #

Do you wish for your records to be sent to your PCP?

Yes No

PHARMACY INFORMATION

Pharmacy’s Name

Address

City/Zip

Pharmacy’s Phone #

INSURANCE INFORMATION

Primary Insurance Name

Subscriber ID

Secondary Insurance Name

Subscriber ID

** INSURANCE CARD(S) OR PROOF OF INSURANCE MUST BE PRESENTED AT THE TIME OF SERVICE**

I hereby voluntarily consent to evaluation and treatment by the healthcare providers of Heart MD, which may include routine diagnostic procedures, physical examinations, medical treatments, and other services deemed necessary for my care. I understand that all procedures will be explained to me and that I have the right to ask questions and decline treatment to the extent permitted by law. I understand that my care may involve multiple healthcare professionals under the direction of my provider. I also consent to the sharing of my health information within Heart MD for purposes of coordination and continuity of care. I also give my permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.

DISCLOSURE AGREEMENT

I recognize that I am responsible for providing my insurance information to Heart MD at the time of service. If I do not have this information, I must pay for my visit at the time of service. I hereby assign all medical benefits, to which I am entitled, including Medicare, commercial insurance, and other plans to Heart MD. I agree to pay for all medical services I receive from the physicians of this practice that the insurance company refuses to pay for whatever reason. This office will file a claim on your behalf. However, if my insurance company denies payment for any reason (non-covered services, terminated coverage, my failure to secure an authorization or referral from the insurance company), I will pay for service upon written/verbal notice of their refusal. I understand that if my insurance carrier requires a referral prior to seeing a specialist, our office must receive the referral before arrival. If we do not have it upon you signing in for your appointment, your appointment will be rescheduled, or full payment must be made prior to the visit. I understand that if I do not have medical insurance, I am responsible to pay for all the services that are rendered. In the event that the patient does not meet their financial obligation, the patient will be discharged from the practice.treatment to the extent permitted by law. I understand that my care may involve multiple healthcare professionals under the direction of my provider. I also consent to the sharing of my health information within Heart MD for purposes of coordination and continuity of care. I also give my permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.

Past Medical History (Please check all that apply)

High blood pressure (Hypertension) Low blood pressure (Hypotension) High cholesterol Heart attack (Myocardial infarction)

Date

Coronary artery disease

Cardiac stents?

Yes No

Hx of Bypass?

Yes No

Valve disease – specify:

Pacemaker or defibrillator

Type

Date

Stroke or TIA (mini stroke)

Date

Surgical History – Past 5 years

Hospitalizations – Past 6 months – Please list hospital and reason

Smoking History

Are you a current smoker?

Yes No

If yes, when did you start smoking?

How many cigarettes do you smoke per day?

Are you a former smoker?

Yes No

If yes, when did you quit smoking?

Do you vape?

Yes No

Do you chew tobacco?

Yes No

Other History

Do you exercise?

Yes No

If yes, how often?

Do you consume Caffeine?

Yes No

If yes, how many cups per day?

Do you drink Alcohol?

Yes No

If yes, how many times per week?

Allergies – Please list any known allergies

Medications – Please include all prescription including over the counter medications.

Medication Name

Dose

Frequency

Family History

Adopted, Family history unknown

Father

Alive Deceased

Mother

Alive Deceased

Siblings

Alive Deceased

Paternal GF

Alive Deceased

Paternal GM

Alive Deceased

Maternal GF

Alive Deceased

Maternal GM

Alive Deceased

Paternal Uncle

Alive Deceased

Paternal Aunt

Alive Deceased

Maternal Uncle

Alive Deceased

Maternal Aunt

Alive Deceased

Son(s)

Daughter(s)

Information

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