SYMPTOMS - Check symptoms you currently have or have had in the

By Dan Shaw,2014-05-01 14:49
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SYMPTOMS - Check symptoms you currently have or have had in the

    Endocrine and Diabetes Associates, LLC Drs. Petrick, Liu, Chanduvi, Shetty, and Gupta Patient Name: SSN: DOB: Sex: Marital Status: PATIENT INFORMATION / / Race: Ethnicity: Preferred Language: Hispanic Other Pacific Islander Hispanic American Indian or Alaska Native

     Asian Other Native Non-Hawaiian Hispanic Black or African American White

    Street Address Home # Work# Ext:

    City, State, Zip Fax# Cell#


Primary Care Physician Referring Physician eMail:


    Guarantors Last Name: First Name MI Work#

    Street Address City, State, Zip Home#

Employer Employer Address


    Insurance Company ID# Group#

    Address City, State, Zip Phone#

    Policy Holder’s Name Policy Holder’s DOB Policy Holder’s SSN

    Policy Holder’s Employer Patient Relationship to Policy Holder Insurance Effective Dates Visit CoPay


    Insurance Company ID# Group#

    Address City, State, Zip Phone#

    Policy Holder’s Name Policy Holder’s DOB Policy Holder’s SSN

    Policy Holder’s Employer Patient Relationship to Policy Holder Insurance Effective Dates Visit CoPay


    Name Phone Relationship

    1. FINANCIAL RESPONSIBILITY I certify that the information I have provided regarding my insurance coverage is correct and authorize Endocrine & Diabetes Associates to verify the insurance coverage and benefits allowed in accordance with my insurance plan’s policies. I authorize that payment be made directly to Endocrine & Diabetes Associates for all medical benefits which are payable under the terms of my insurance policy for the services provided. I agree to pay copayments, coinsurance, or deductible, are required by my insurance plan. I understand that I am responsible for knowing the terms and regulations of my insurance plan, and I agree to accept full responsibility for payment if my insurance plan is invalid. I will be responsible for all lab charges denied for insurance payment if I have not notified Endocrine and Diabetes Associates of lab billing problems within 10 days of receiving a bill from the laboratory. I will be charged a $75 fee for appointments missed without 24 hours notice. I will be assessed a $40 bank fee for any check returned by my bank. An account unpaid after repeated notification will be forwarded to IC Systems Inc. for collection. A collection fee of 35% will be assessed. 2. RELEASE OF MEDICAL INFORMATION I hereby authorized Endocrine and Diabetes Associates to submit a claim to my insurance company for medical services provided to me or my dependant, to provide a copy of this release and a copy of medical records related to such services if requested by the payor, and to release medical information to my primary care or consulting physicians to assist with continuity of my health care. This release will remain in effect until I cancel this release in writing. 3. NON-COVERED SERVICES I agreed to pay for medical services provided to me or my dependant which are not covered by the benefits in my insurance plan. I Agree To The Above Stated Responsibility and Consent: Date: Signature of Patient or Legal Guardian



     Patient Name Today’s Date

     Age Birth Date Date of Last Physical Examination

     What is your reason for visit?

    SYMPTOMS - Check ( ;) symptoms you currently have or have had in the past year.

    GENERAL GASTROINTESTINAL EYE, EAR, NOSE, THROAT MEN only Chills Appetite poor Bleeding gums Breast lump Depression Bloating Blurred vision Erection difficulties Dizziness Bowel changes Crossed eyes Lump in testicles Fainting Constipation Difficulty swallowing Penis discharge Fever Diarrhea Double vision Sore on penis Forgetfulness Excessive hunger Earache Other Headache Excessive thirst Ear discharge WOMEN only Loss of sleep Gas Hay fever

     Loss of weight Hemorrhoids Hoarseness Abnormal Pap Smear Nervousness Indigestion Loss of hearing Bleeding between periods Numbness Nausea Nosebleeds Breast lump

     Rectal bleeding Sweats Persistent cough Extreme menstrual pain

    MUSCLE/JOINT/BONE Stomach pain Ringing in ears Hot flashes Pain, weakness, numbness in: Vomiting Sinus problems Nipple discharge Arms Hips Vomiting Blood Vision Flashes Painful intercourse Back Legs Vision Halos Vaginal discharge CARDIOVASCULAR Feet Neck Other SKIN Hands Shoulder Chest pain Date of Last High blood pressure Bruise easily Menstrual Period GENITO-URINARY Irregular heart beat Hives Date of Last Blood in urine Low blood pressure Itching PAP Smear

     Frequent urination Poor circulation Change in moles Have you had a Lack of bladder control Rapid heart beat Rash Mammogram

     Painful urination Swelling of ankles Scars Are you Varicose veins Sore that won't heal pregnant No. of children

    CONDITIONS - Check ( ;) conditions you have or have had in the past,

     AIDS Chemical Dependency High Cholesterol Prostate Problem Alcoholism Chicken Pox HIV Positive Psychiatric Care Anemia Diabetes Kidney Disease Rheumatic Fever Anorexia Emphysema Liver Disease Scarlet Fever Appendicitis Epilepsy Measles Stroke Arthritis Glaucoma Migraine Headaches Suicide Attempt Asthma Goiter Miscarriage Thyroid Problems Bleeding Disorders Gonorrhea Mononucleosis Tonsillitis Breast Lump Gout Pacemaker Tuberculosis Bronchitis Heart Disease Pneumonia Typhoid Fever Bulimia Hepatitis Polio Ulcers Cancer Hernia Vaginal Infections Cataracts Herpes Venereal Disease

     MEDICATIONS List medications you are currently taking. ALLERGIES To medications or substances.

    May we retrieve your prescription drug history from your Pharmacy Name Phone pharmacy? Yes No

FAMILY HISTORY Fill in information about you immediate family.

    Check if any of you blood relatives had any of the following: State of Age at Relation Age Cause of Death Health Death Disease Relationship to You Father Arthritis, Gout Mother Asthma, Hay Fever Brothers Cancer

     Chemical Dependency


     Heart Disease, Strokes Sisters High Blood Pressure,

     Kidney Disease


     Other HOSPITALIZATIONS PREGNANCY HISTORY Year of Sex of Year Hospital Reason for Hospitalization and Outcome Complications if any birth birth

     HEALTH HABITS Check ( ;) which substances

    you use and describe how much you use.

     Caffeine Have you ever had a blood transfusion? Yes No Tobacco If yes give approximate dates: ___________________________________________________ Street Drugs


     OCCUPATIONAL CONCERNS Check ( ;) if your work exposes you to the following


     Hazardous Substances

     Heavy Lifting


    Your occupation:

    To the best of my knowledge the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Date Print Name of Patient, Parent, Guardian or Personal Representative Relationship to Patient Reviewed By Date

Endocrine and Diabetes Associates, LLC

    Patricia A Petrick, MD FACP 6001 Montrose Road, Suite 211 Linda Liu, MD FACP Rockville, Maryland 20852 Beatriz H. Chanduvi, MD FACE Phone 301-468-1451 Archana Shetty, MD Fax 301-468-3580 Anurag Gupta, MD




     SOC SEC or ID #

     I hereby authorize

     (name of your doctor or facility)


     ( address)

    to furnish information from my medical records, to include history/exam,

    laboratory and/or radiology reports, and any information pertinent

    to my appointment at Endocrine and Diabetes Associates, LLC.


     ; Patricia A. Petrick, MD ; Beatriz Chanduvi, MD

     ; Linda Liu, MD ; Archana Shetty, MD

     ; Anurag Gupta, MD

     Endocrine and Diabetes Associates LLC

    6001 Montrose Road, Suite 211

    Rockville, Maryland 20852

    FAX: 301-468-3580

    This authorization shall expire without my express revocation one year from the date written below. I understand that I

    have the right to withdraw this authorization at any time, except to the extent that action has been taken on this


     Signature of Patient or Guardian Date

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