PATIENT INFORMATION

First Name:

Last Name:

Social Security Number:

Native/Preferred Language:

Address:

Date of Birth:

Home Number:

Cell Number:

Gender:

City:

Employment/Student Status:

Zip:State:

Family Doctor:

Marital Status:

Referring Doctor:

Occupation:

Employer/School:

Ethnicity:

Email:**By providing your e-mail address, you allow Medical Associates of Erie to send personal information to you via e-mail. We can

also use e-mail for appointment confirmation. If you prefer that we do not contact via e-mail, please mark decline.**

Emergency Contact:

Phone Number: Relationship:

Male Female

Hispanic or Latino Decline to answer Not Hispanic or Latino

Relationship:

Relationship:

Healthcare Proxy:

Account Information: Is the above referenced patient over the age of 18? Yes NoIf yes, the patient is legally responsible for all financial obligations to this office.

Work Number:Cell Number:Home Number:

Social Security Number:Date of Birth:

If No, who is financially responsible for this account?

Employer:

Middle Initial:

Hearing Vision Cognitive

Race: CaucasianAfrican American AsianAmerican Indian/Alaska Native Hawaiian/Pacific IslanderHispanic or Latino

Phone Number:

Primary Caregiver:

Legal Guardian:

Phone Number:

Communication Needs:

Phone Number: Relationship:

Decline e-mail

Decline to answer

The following have been completed (please provide a copy of any documents for your medical record):Advance Directive for Health Care Living Will Physician Orders for Life Sustaining Treatment

Zip:State:City:Address:

Pharmacy Preference:

Work Number:

Relationship to Patient:

Pg. 2 Patient Name:

Insurance information: Please provide your insurance card(s) to the receptionist. This will be scanned into our system to enable us to submit claims to your insurance company on your behalf. If the patient is not the policy holder for their primary, secondary or tertiary insurance please list the subscriber's information below:Primary Insurance Company: Effective Date:SUBSCRIBER Information for this Policy

Date of Birth:

Cell Number:Home Number:

First Name:Last Name:

MI:

Self SpouseChild Other

ID or Policy #:Group #:Name of Employer:

I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS, AND REQUEST PAYMENT OF BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS OR PARTICIPATES.

Date:SIGNED:

SIGNED: Date:

I UNDERSTAND THE PROVIDER'S CHARGES MAY EXCEED THE INSURANCE PAYMENTS, AND IF GREATER THAN SUCH PAYMENT, I WILL BE RESPONSIBLE FOR THAT AMOUNT. SHOULD MY ACCOUNT EVER BECOME DELINQUENT

AND ELIGBLE FOR COLLECTION, I UNDERSTAND AN APPROPRIATE COLLECTION FEE WILL BE ASSESSED.

Zip:State:City:Address:

Relationship to Patient:Male FemaleGender:

Secondary Insurance Company:SUBSCRIBER Information for this Policy

Last Name:First Name:

Address:Date of Birth:

SelfChild Other

SpouseRelationship to Patient:FemaleMale

MI:

City: Zip:State:

Cell Number:Home Number:

Effective Date:

Gender:

Tertiary Insurance Company:SUBSCRIBER Information for this Policy

Last Name:First Name:

Address:Date of Birth:

SelfChild Other

SpouseRelationship to Patient:FemaleMale

MI:

City: Zip:State:

Cell Number:Home Number:

Effective Date:

Gender:

Name of Employer:Group #:ID or Policy #:

Name of Employer:Group #:ID or Policy #:

Date of Birth:

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

By signing below, I acknowledge that I have received and understand or refused a copy of this office's Notice of Privacy Practices Form which contains a description of the uses and disclosures of my health information. I further understand that this office may update its Notice of Privacy Practices at any time and that I may receive an updated copy by submitting a request in writing for a current copy of this office's Notice of Privacy Practices Form.

Date

If completed by patient's personal representative, please print name and sign below.

DateSignature of Patient's Personal Representative

Print Patient's Personal Representative Name Relationship to Patient

Release of Information Authorization I hereby authorize Medical Associates of Erie or any agent to release the following medical information:

Consultant/Procedure Results Answers to Medical QuestionsTest Results

The above items may be released to the following person(s):

Staff to complete if unable to obtain signature of patient and patient's personal representative. Office staff made a good faith effort to obtain written acknowledgement from the patient and patient's personal representative of the Notice of Privacy Practices, but was unable to do so for the reasons documented below:

Patient and patient's personal representative refused to sign

DateSignature of Employee

Print Employee Name

Relationship:Name:

Patient and patient's personal representative unable to signOther:

Relationship:Name:Relationship:Name:

Relationship:Name:

Relationship:Name:Relationship:Name:

Signature of Patient

Print Patient's Name

Please describe/explain the reason for today's appointment:

REVIEW OF SYSTEMS: Please check all that apply.

ChillsDecline in Health

FeverFatigue

Weight Loss

WeaknessWeight Gain

Constitutional

PainHeadachesHead InjuryFaintingDizziness

Head

Eyeglass/Contact UseEye Pain

Excessive TearingDouble VisionDischargeCataractsBlurry Vision

Eyes

RednessRecent InjuryPain with LightInfectionsGlaucoma

Vision LossUnusual Sensations

Mouth

Tongue BurningPostnasal Drip

Frequent Sore Throats

DischargeHearing AidHearing Impairment

PainInfections

Ringing in Ears

Sinus Infections

Nosebleeds

InfectionsFrequent ColdsDischarge

Nose

Nasal Obstruction

Ears

Throat & NeckEnlarged Tonsils

Tenderness

Wheezing

Runny Nose

Coughing BloodCough

Pain with Breathing

Bringing up SputumRespiratory

Heart MurmurExtremity(s) DiscoloredExtremity(s) CoolChest Pain

PalpitationsHigh Blood Pressure

Wheezing w/ Exertion

Short of BreathShort of Breath w/ ExertionSwelling of Legs or Feet

Muscle CrampsJoint StiffnessJoint Pain

Back ProblemsArthritis

Gout

Musculoskeletal

DepressionBehavioral Changes

Restricted MotionParalysis

Excessive Stress

Psychiatric

Muscle Stiffness

Hallucinations

Varicose VeinsBruising

Nail Texture Changes

EczemaHair Texture ChangesHives

Loss of HairItching

Lumps

Pitting Nails

Mole Increased Size

Rash

Loss of ConsciousnessBlackouts

Ulcer or WoundSkin Color Change

Neurological

Tingling or BurningSeizures

Endocrine

Dryness

Nail Growth Changes

Disturbing Thoughts

Memory LossMood Changes

Skin

Numbness

Bleeding GumsChange in DentitionHoarseness

Voice Changes

Lumps

Cardiovascular

DiarrheaConstipationChange in Stools

Black Tarry StoolsAbdominal Pain

Gastrointestinal

HeartburnHemorrhoidsNauseaRectal BleedingRectal PainTrouble Swallowing

Change in Appetite

VomitingVomiting Blood

NervousnessBreasts

DischargeLumpsPainTenderness

Cold Intolerance Excessive UrinationGoiterHeat IntoleranceHot FlashesIncreased ThirstSweats

Hematologic/LymphAnemia Bleeds EasilyBlood ClotsEasy BruisabilityEnlarged Lymph NodesLow Blood Cell Counts

Itchy EyesSeasonal AllergiesSneezingWatery Eyes

Allergic/Immunologic

Urinary

Retention

Flank Pain

Urgency

Frequency

Urine Discoloration or Odor

PainLesions

Incontinence

Disorientation

Unsteady Gait

Awakening to Urinate

Burning or Pain w/ UrinationBlood in Urine

Difficulty Starting Stream

Tremors

Genitals Male Female

Itching

Discharge

Venereal DiseaseSexual Problems

Irregular Menstruation

Date of Birth:Patient Name:Pg. 4

Pg. 5

No Known Allergies

Name of Medication Dosage (e.g. mg/pill) Times per Day

I am not currently taking any medications.

Yes NoWere you adopted? Family History Unknown

Patient Signature:

Medication List Attached Additional Medications Listed on Back of Form

Allergies or Intolerance to Medications or Food (include type of reaction):

MEDICATIONS: Please list (or attach a copy) all prescription and non-prescription medications, vitamins, home remedies, birth control, herbs, inhalers, etc.

FAMILY HISTORY: Please note below any history of medical problems in the family. Please include details such as relationship of family member and if they are alive or deceased.

CONSENT FOR MEDICATION HISTORY REVIEW: I authorize Medical Associates of Erie to obtain an electronic record of my medication history to aid in the complete documentation within my medical record.

Date of Birth:Patient Name:

Pg. 6

Yes NoDo you Smoke? Have you ever Smoked? NoYesPacks per Day:

Number of Years:

Do you use any other tobacco products? Yes No

Please Specify:

Yes NoDo you Drink Alcohol?

Drinks per Week:Do you Drink Caffeine?

Drinks per Week:

Please Specify:

Yes NoDo you use Recreational Drugs?

Last Used:

Some College Some High School High School Graduate GEDCollege GraduateVocational School Post Graduate Degree

Education:

Arts & Crafts

Gardening Hiking

Camping Computers DancingCars

Hunting Motorcycle or Bike Riding Music

Hobbies/Interests:

Fishing

Other:Reading Spectator Sports

Have you had any environmental exposure such as asbestos, coal inhalation or second hand smoke?

Yes No Please Specify:

Have you had any exposure to TB (tuberculosis)? When:NoYes

Yes NoDo you live alone? Members of you Household:

Location of Service:

Type: Beer LiquorWine

Yes No

When did you serve?Branch:Yes NoMilitary Service?

Where:Yes NoHave you recently lived or traveled to a foreign country?

Please Specify:Yes NoDo you have any pets?

Yes NoDo you have any known risk factors for HIV/AIDS?

PAST MEDICAL HISTORY: Please list any past medical conditions with pertinent details including recent hospitalizations and/or ER visits.

SOCIAL HISTORY: Please check the appropriate option.

MISC SOCIAL HISTORY: Please check the appropriate option.

Date of Birth:Patient Name:

No Surgical History

Pg. 7

Test Date Office/Physician ResultBone Density (DEXA)

Colonoscopy

Dental Exam

Eye Exam

Flu Shot

Hemoglobin A1C

Hepatitis C Screening

Hepatitis Vaccine

Mammogram

Pap Smear

Prevnar 13

Pneumovax 23

Shingles Vaccine

Name of Person Completing Form:Relationship to Patient:

SURGICAL HISTORY: Please list any procedure or surgery that you have had and include any abnormal findings or complications.

HEALTH MAINTENANCE: Please note any details regarding screenings or other physician visits you have had.

OBSTETRIC HISTORY: For Women Only.

Total Pregnancies Full Term Premature Abortions Miscarriages Ectopics Multiple Births Living

Date of Birth:Patient Name:

Tetanus Vaccine

Other

Other

Revised 2/2014 Revised 8/2015 Revised 8/2016

Revised 12/2016