Martin Downs Medical Center Kenneth L Moiling MD PA 938 SW Martin Downs Blvd Palm City, FL 34990

Name: Address: Phone Number:

Age:.

Pharmacy Name:

Phone:.

Pharmacy Address:

Past Medical History Have vou ever had, or been told that vou have the following: Please check those aBPJY Asthma

High Blood Pressure Nervous Breakdown Tuberculosis.... Rheumatic f:ever ___ Depression _..__ Sinusitis _ Stomach Ulcers _.. _ Epilepsy (seizures) Nasal Polyps Hepatitis Stoke or Paralysis Hay Fever Cirrhosis Diabetes Pneumonia Colitis _ Arthritis Bronchitis Diverticulitis .._ . Gout Gallstones Thyroid Disease Emphysema Pancreatitis Cancer (where) Heart Disease Kidney Stones Anemia Anqina

Suraeries Type of suraery:

Date:

What Hospital:

Type of suroery:

Date-

What Hospital:

Type of suraery:

Date:

What Hospital:

Type of suraerv:

Date:

What Hospital:

Tvoe of suraerv.

Date:

What Hospital:

_

Allergies Are you allergic to any medication, or do you have any oilier allergies?.. .Yes No. If YES, please list the agent to which you are allergic and state the type of reaction you experience: Medication

Type of Reaction

Medications Please list below ALL medications you now take. Please list the strength tint! how many time day you are taking these medications. Including all Osver the counter medications.

Name of Drug

What Strength

How Often; If daily, how many times a day?

Injuries Have you ever had any major injuries? Head Injury Eye Injury Neck Injury Back Injury

What Year What Year What Ycar___.__ What Year . ..

No:_, _____

Yes:

. If Yes. please check below.

Automobile Injury Gunshot Wound Other Other

_

What Year What Year What Year___ What Year

Tobacco Please check all that applies to you: ______

I am a life long NON-Smoker.

I no longer smoke but I smoked I quit smoking

packs of cigarettes per day for

_ years.

years ago.

I currently smoke

packs of cigarettes per day for the last

number of

years, .__ I smoke or smoked a pipe / cigars for choices.

years, (please circle the appropriate

Transfusions Have you ever received a blood transfusion? No for the transfusion:

Yes

If YES, please state the reason

Alcohol Please check all the applies to you: I do not drink alcohol I drink socially, but not to excess. I drink

oz. of alcohol per day about „

days per week.

Occupational History Check one or more: Retired

. Self Employed Housewife

Employed (by others)

Student.

._ Unemployed

If employed list below previous occupations from your first job to your current job.

1.

.__. 2.

3.

4.

S.

6.

7.

8.

9.

Have you ever worked at any of the following occupations? No check all that apply and indicate how long, __ in a foundry, how long ._ __ in a coal mine, how long . _jn any other mining; list the type

If Yes, please

.__ as a tunnel worker, how long as a sandhlaster, how long. __ as a rock cutter, how !ong_ . .in manufacturing bery!lium_ In manufacturing ceramics, glass or any other abrasives. in any other job with exposure to dust, gas or fumes Describe the job:_

jn a quarry, how long.. in a pottery, how long in a cotton, flax or hemp mill_ ._in asbestos mining, milling processing, painting, spraying. __

Education Circle year completed: Grade School 1 2 3 4 5 6 7

College 1 2 3 4

High School 1 2 3 4

Other

Hobby & Leisure History Do you have contact with animals in your home? No below: . ___.. Birds Dogs __ Cats

Yes

Do you have hobbies in which you may inhale fumes or dust? No please give details: _

If Yes, please check „_. Yes

Other „ If Yes,

Family History

Please check and describe where appropriate: Father;

Living - Age

Illnessess;

.....

___ Dead - Age at Death

Cause

Mother:_

._ Living - Age.

Illnessess:

_. _„______„.

Dead - Age at Death

Cause_

Brothers and Sisters Living - Age Illnessess^ Living - Age.

Illnessess

Living - Age

Illnessess

Dead - Age at Death

Cause__

Dead - Age at Death__

Cause

Dead - Age at Death

_____ .

Cause

If any of your BLOOD relatives have had the following conditions check and indicate their relationships to you. _ Asthma...._. ___ Tuberculosis Diabetes

High Blood Pressure....,__. Stroke

________

_Heart Disease....

Arthritis .. _

Gout

__

Epilepsy Cancer

_

__0ther

_______

__Other

_____ ..___

.

Vaccinations If you have had any of the following, check and if possible give the date of the last vaccination or booster: Influenza (FLU)

20__ ___

_______

Pneumococcal (Pneumonia)

20

Review of Systems Weight: Present:. .._ Usual, _ Any weight changes in the past year? Yes__ Skin: Chronic or recurring skin conditions? Yes Lump or growth on skin? Yes No. Change in color or skin? Yes_ _____ No, Eyes: Glasses_.___ Decreased vision... Pain in eyes_____ Ears: Difficulty hearlng___ Earaches_ Discharge from ears —__ Buzzing or ringing in ears___. — Nose & Throat: Frequent sneezing Nose continually stuffed or runny. Recurrent sore throat ___ Persistent hoarseness __„ Cardiopulmonary: Chest Pain Shortness of breath, Cough__ Bloody Sputum Wheezing. Unusual heart beat Gastrointestinal: Frequent heartburn or indigestlon_ Nausea or vomiting Stomach pains Diarrhea^ Constipation. . Blood in stool Genitourinary: Painful urination Frequent urination^ Bloody urine Discharge

No

Musculoskeletal: Painful joints Sore muscles Back pain Neuropsychiatric: Frequent or severe headaches Dizziness or faintness More nervous than the average person ._____„ Please check below if you have had any of the following in the past two years and indicate the date: Complete Medical Exam Electrocardiogram Blood Count Blood Chemistries. Chest X-Ray_ Cat Scan of Chest Pulmonary Function Test. (Breathing Test)

New Patient Information Form Name: Home Phone:

Cell Phone;

Work Phone:

Email Address: Home Address:..

Zip',

Social Security:,

Date of Birth:.

Spouse's Name:.

Spouse's Cell:_

Out Of Town Address;, State:

___

City:.

Primary Care or Referring Physician:,

__ Zip:.

Phone:

Whom may we contact in the case of an emergency?. Who is responsible for the bill? Did you sustain an injury at work? Y N Are you covered under an employer or union policy Y N Are your injuries accident related? Y N Is your spouse or family member employed?

YN

Are you currently employed?

YN

Y N So you have a secondary insurance policy?

I understand and agree that, regardless of my Insurance status, I am ultimately responsible for the balances of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or the above information.

Signature

Date

Cancellation Policy; We ask for 24 hour notice to reschedule or cancel appointments. This allows us to schedule another patient In your place. If an emergency arises, please give us as much notice as possible. Failure to show up to a scheduled appointment, without a cancellation phone call, will be subjected to a $35.00 No Show Fee. I have read the above and understand the cancellation policy:

Signature

Date

Martin Downs Medical Center Kenneth L Moiling MD PA 938 SW Martin Downs Blvd Palm City, FL 34990

Consent for Treatment, Payment and Healthcare Operations 1 consent to the use or disclosure of my protected health in form all on by Stuart Lung for the purpose of diagnosing or providing treatment to me, obtaining payment fnr my healthcare bills ur to conduct healthcare operations of Stuart I.ung. I understand that diagnosis or treatment of me, by Dr Kenneth L Hulling may be conditioned upon my consent as evidence by my signature on this document. 1 understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice, Stnitrt Lung is no! required to agree to the restrictions that 1 may request. However, if Stuart Lung agrees to a restriction that I request, the restriction is hinding to Dr Kenneth L Hulling. I have the right to revoke this consent, in writing, nt any lime, except lo the extent that Dr Kenneth L Hailing has taken action in reliance on this consent. My "Protected Health Information" means health information, including my demographic information, collected from me and created or received by my physician, another- health care provider, a health plan, my employer or a health care clearinghouse. This protected health care information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe Ihe information may identify me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performances of health can: operations of Stuurt Lung. The Notice: of Privacy Practices for Stuart Lung is also available in the patient waiting room, This Notice of Privacy Practices also describes my rights and the Swart Lung duties with respect to my protected henllh information. Stuart Lung reserves the right to change the privacy practices that arc described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by catling and request ing a revised copy be sent in the mail or asking for one at the time of my next appointment.

I authorize payment of medical benefits to he paid directly to KENNETH L ROLLING MD PA for services provided to me. I understand that I am responsible for all charges regardless of insurance status as well as any associated costs for collection. I agree that this authorization shall be valid until rescinded in writing.

Sign ti In re of Patient or Personnl Uupreseiilnlive

Printed Name of Patient or Personnl Representative

Dtite

Martin Downs Medical Center Kenneth L Rolling MD PA 938 SW Martin Downs Blvd Palm City, FL 34990

Notice of Privacy Practices; A copy of our Privacy Practice and Patient Bill of Rights is available in a binder in our lobby. You may request a copy if desired at no charge. By signing this you acknowledge you have been informed of our office procedures regarding Privacy Practices. Date

Patients Signature

Protected Health Information is not permitted to be released to the following:

Incidental Disclosure: (TO BE FILLED OUT BY OFFICE STAFF)

Requested To Amend Protected Health Information: (TO BE FILLED OUT BY OFFICE STAFF)

Martin Downs Medical Center Kenneth L Holling MD PA 938 SW Martin Downs Blvd Palm City, FL 34990

COMMUNICATION CONSENT

* * Leave message on my answering machine and or fax machine to confirm appointments. ** Speak to the family members in my house and leave a message with them regarding my healthcare or billing arrangements. ** Call me at my place of employment to confirm ail appointment. ** Leave minimal medical data on my answering machine and or fax machine regarding medications, treatments and or test results.

Patient's Name (Please Print) Signature of Patient Date

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Recipient's Name

Martin Downs Medical Center Kenneth L Rolling MD PA 938 SW Martin Downs Blvd Palm City, FL 34990

Recipient's Address: City:

State:

Phone No.:

Fax:

Zip:

Date of Birth

P a t i e n t Name: Social Security No.:

Patient's Address:

Medical Record No.:

City:

Zip:

State:

This authorization will expire 60 days after signature unless otherwise indicated below; Dale of expiration: I understand that: Please check the items below that yon want disclosed: u a a a a a Q a

All PHI in medical record Office dictation Operative Reports Consults History & Physical Diagnostic Testing Lab results Other: (Please Specify

1. 2.

3.

4.

5.

6.

! may refuse to sign lliis authorization and lhat it is strictly voluntary. My treatment, payment, cnrollmenl or eligibility for bencfj is may not he conditioned on s i g n i n g this authorization. I may revoke this authorization ai any time in writing, but if! dr., it will -lot have »\\y affect on any actions taken prior to receiving the revocation. Further deliils may be found in the Notice of Privacy Practices. If the requester or receiver is nol a health plan or h e a l t h care provider, the released information may no longer be protected by federal privacy regulations and may be tcdiscloscd. I understand that I may see and obtain a Copy of the Information described on this form, for a reasonable copy fee, i f ! ask for it. 1 may obtain u copy ofthis form after 1 sign if requested.

and authorize KENNETH L. HOU.IN6 M.D PA Health Information to the above named entity. .Signature of Patient e of Patient

Date Relationship to P a t i e n t

to re i ea se

my protected