Senior Health Clinic LewisvilleMedical City

The Senior Health Clinic at Medical City Lewisville accepts Medicare and Managed Medicare for patients ages 65 and older.

We’re located on the southeast side of the Medical City Lewisville campus at the Elm Street Entrance.

Call (469) 370-2677 to schedule an appointment today!

For more information, visit our website: https://medicalcitylewisville.com/service/ senior-health-clinic.

500 WEST MAIN STREET, LEWISVILLE, TX 75057 | PHONE: (469) 370-2677 | FAX: (469) 370-2671

To our new patients:

On behalf of the staff at the Senior Health Clinic, we would like to welcome you as a new patient. Enclosed is a packet of information we will need you to fill out and bring with you to your appointment. We will review your completed patient information packet and make copies of your insurance cards. YOUR ID AND INSURANCE CARD(S) ARE REQUIRED AT EVERY VISIT. We also request you bring all medication including prescription medications, over the counter medications, herbal supplements and vitamins with you to EACH APPOINTMENT. The physician and nurse will review your medications at each visit.

Your new patient appointment is scheduled for _________________ on _________________.

At your first appointment we will be gathering a lot of demographic, medical and insurance information. Because of the lengthy appointment, it is imperative that you arrive 30 minutes prior to your scheduled appointment time. If you are late it may be necessary to reschedule your appointment.

Our goal is to provide not only high-quality medical care, but to attend to our patient’s and families’ overall well-being.

Because the Senior Health Clinic is an outpatient department of Medical City Lewisville, the hospital bills a “facility fee” for each visit to this outpatient clinic. You will receive a bill from Medical City Lewisville for the facility fee. This fee covers the cost of the clinic staff, supplies, equipment and space.

You will also receive a separate bill from the physician. The physician’s fee includes the physician’s time and services as well as interpretation of testing performed in the clinic. All Medicare plans as well as supplemental policies recognize these charges and will pay once deductibles are met. You will be responsible for deductibles and or co-pays, depending on your plan coverage. The hospital as well as the physician billing service (Quest) will bill all Medicare plans as well as secondary insurance providers.

SINCE MEDICARE NOW PROVIDES MEDICARE SUMMARY NOTICES ONLY ON A QUARTERLY BASIS, YOU CAN OBTAIN MORE TIMELY INFORMATION ON EACH SERVICE BY REGISTERING WITH AND ACCESSING www.MyMedicare.gov.

If you have any questions regarding our services or these enclosures, feel free to call the office at (469) 370-2677 or contact me directly at (469-370-2672).

We thank you for choosing Medical City Lewisville to address your health care needs, and we look forward to serving you.

Sincerely,

Susan Baby, MSN, APRN, AGNP-C, CMSRN Director Senior Health Clinic & Nurse Practitioner

500 W. MAIN ST. | LEWISVILLE, TEXAS, 75057 | PHONE: 469.370.2677 | FAX: 469.370.2671

PATIENT PORTAL USER INSTRUCTIONS:

1. Once a Senior Clinic staff member activates your Patient Portal account, you will receive an email with your User ID and Temporary Password. Please make a note of these, as you must enter these exactly as they appear (upper-or lowercase.) This email also highlights some of the features of Portal, AND THE LINK TO OUR PATIENT PORTAL.

2. Once you have made note of your login details, click the "login URL" link. This will open the portal login screen.

3. Enter the exact User ID (User Name) and Password and click "Login." If you ever forget these credentials, or have issues logging in, click the "Can't access your account?" link and get help retrieving either the Username, Password, or both. If you are still unable to access, please contact the office.

4. When you log in for the first time, you must validate your identity. You are required to answer one of the questions in order to authenticate yourself. Click "Submit." (This is an added layer of security for first time users.)

5. Now, you must set up your permanent password and security question.

6. Choose a default security question, or create your own. Make sure the answer to the question is easily remembered. Try to keep your answer short. Once these are completed, click "Submit."

7. Congratulations! You have now successfully accessed your personal Patient Portal account! Your Portal "Dashboard" or home screen gives you an overview of your upcoming appointments, messages, current medications, latest lab results and etc.

500 W. MAIN ST. | LEWISVILLE, TEXAS, 75057 | PHONE: 469.370.2677 | FAX: 469.370.2671

Patient Records Request

Today’s Date: ____________________________________

Patient Name: ___________________________________

Patient Date of Birth: ______________________________

Type of records needed:

o Office Visit Notes o Radiology Reports o Laboratory Results

Dates of records being requested:

o January 2015 to Present o Last hospital visit or office visit

Dr. Afeefa Chaudhry is requesting records on the above named patient for continuation of care. Thank you for your attention to this matter. If you have any questions or concerns, please feel free to contact the Senior Health Clinic at Medical City Lewisville.

Patient Signature Date

500 W. Main St. | Lewisville, Texas, 75057 | PHONE: 469.370.2677 | FAX: 469.370.2671

NEW PATIENT INFORMATION FORM

PHYSICIAN'S NAME

PATIENT'S FULL NAME:

ADDRESS: APT. # PHONE NUMBER ( ) -

EMAIL:

CITY STATE ZIP CODE WORK NUMBER ( ) -

CELL NUMBER ( ) -

SEX: M F DATE OF BIRTH MARITAL STATUS: (MM/DD/YY)

PATIENT'S EMPLOYER:

EMPLOYER'S ADDRESS

Married Single

Widowed Divorced

PATIENT'S SOCIAL SECURITY # - -

OCCUPATION

PHONE NUMBER RELATIONSHIP CONTACT: IN CASE OF EMERGENCY

( ) -

ADDRESS: ALT. PHONE NUMBER ( ) -

CITY/STATE: ZIP CODE:

INSURANCE INFORMATION

PRIMARY COVERAGE, CARRIER NAME:

SECONDARY COVERAGE, CARRIER NAME:

ETHNICITY AND RACE (please complete both sections)

ETHNICITY PLEASE CHECK THE BOX BELOW THAT APPLIES TO YOU.

HISPANIC OR LATINO

NOT HISPANIC OR LATINO

RELIGION __________________

HOW DID YOU HEAR ABOUT US?

Physician:

Magazine:

Friend:

Website:

Other:

RACE PLEASE SELECT THE RACIAL CATEGORY WITH WHICH YOU MOST CLOSELY IDENTIFY WITH:

AMERICA INDIAN OR ALASKA NATIVE

ASIAN OR PACIFIC ISLANDER

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN

WHITE OR CAUCASIAN

OTHER (PLEASE SPECIFY):

NEW PATIENT ADMISSION ASSESSMENT AND HISTORY

WE STRIVE TO KEEP ALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT. DATE TODAY:

NAME: D.O.B. LAST FIRST M.I.

REASON FOR VISIT TODAY:

PAST MEDICAL HISTORY: MEDICAL CONDITIONS - Please check current or past illnesses:

High blood pressure High Cholesterol

Congestive Heart Failure Heart Attack

Asthma Kidney Problems

Diabetes Arthritis

Cancer - Type Other

COPD

Liver Disease

PREVIOUS SURGERIES:

HEALTH MAINTENANCE

Test Date

Annual Wellness Exam

PAP Smear

Mammogram

Colonoscopy

Stool Cards

PSA

Cholesterol

Bone Density

Echo

Eye Exam

Flu vaccine

Shingles vaccine

Tetanus vaccine

Pneumonia vaccine

Cataracts Year: Breast Year:

Tonsillectomy Year: Hysterectomy Year:

Appendectomy Year: Pacemaker Year:

Prostate Surgery Year: Gall Bladder Year:

Orthopedic Year: Hemorrhoids Year:

Hernia Year: Heart Bypass Year:

FAMILY HISTORY: Check the box (9) next to the condition that your family member has; then specify their relationship to you after the disease, using the abbreviations as follows: Mother (M), Father (F), Brother (B), Sister (S), Children (C) For example, if your Sister and Mother had breast cancer (9) BREAST CANCER S.M.

Alcoholism Colon Cancer Kidney Disease Other

Anemia Diabetes Mental Illness Other

Asthma Glaucoma Osteoporosis

Arthritis Gout Prostate Cancer

Bleed easily Heart Disease Seizures

Breast Cancer High Blood Pressure Thyroid Disease

OTHER PHYSICIANS YOU ARE CURRENTLY SEEING:

Name Reason:

Name Reason:

Name Reason:

NEW PATIENT ADMISSION ASSESSMENT AND HISTORY

NAME: DOB: AGE:

SOCIAL HISTORY:

Tobacco Used Currently? Y / N # Packs per day: Used in the Past? Y / N When did you stop?:

Alcohol Use? Y / N Beer: Y / N Oz (or glasses or cans per week average)?

Caffeine Use? Y / N Cups per day: Drug use? Y / N

Exercise Regularly? Y / N Type: Times per week:

LIVING ARRANGEMENTS: Lives alone Lives with partner Lives with other

Lives in apartment Lives in Care Facility

Assistive Devices: Cane Crutches Walker Dentures Partial Plate (Upper/Lower)

Prosthetic Limb Hearing Aid Splint / Brace Glasses Contacts

Do you currently have Home Health: Yes No Company:

Do you now or have you in the past 1 month had any problems related to the following systems? Circle Yes or No

y)

Y N

Constitutional

Y N

Endocrine

Y N

Muscles and Bones

Y N

Blood/Lymph nodes

Symptoms Excessive thirst Joint pain or stiffness Enlarged glands (lymphadenopat

Fever Y N Too hot/cold Y N Neck pain Y N Bruising

Y N Chills Y N Weight change Y N Back pain Y N Bleeding

Y N Headache Y N Joint swelling

Y N Sweats

Y N Weight Loss

Other Other Other Other

Y N

Eyes

Y N

Intestines, Colon

Y N

Ear/Nose/Throat/Mouth

Y N

Psychologic

Blurred vision Trouble swallowing Ear pain / hearing loss Satisfied with your life?

Y N Double Vision Y N Nausea/vomiting Y N Sore throat Y N Depressed?

Y N Pain Y N Indigestion/heartburn Y N Nasal congestion Y N Suicidal?

Y N Abdominal Pain Y N Sinus pressure / pain Y N Abused?

Y N Diarrhea/constipation Y N Nose bleeds

Y N Hemorrhoids

Y N Rectal bleeding

Y N Blood stool

Other Other Other Other

Y

Y

Y

N

N

N

Allergies

Hay Fever

Runny nose

Itchy eyes

Other

Y

Y

Y

Y

N

N

N

N

Heart and Blood Vessels

Chest pain

Varicose veins

Rapid heart beat

Edema / Swelling

Other

Y

Y

Y

Y

Y

Y

N

N

N

N

N

N

Urination

Burning with urination

Urgency

Frequency

Blood in urine

Emptying bladder at night

Vaginal discharge, pain, sores

Other

Y

Y

Y

Y

N

N

N

N

N/A

N/A

N/A

N/A

Sexual/Menstrual History

Change in sex drive?

Sexual performance

satisfactory?

Sexual trauma?

Irregular bleeding?

Other

Y N

Neurological

Y N

Skin

Y N

Respiratory

Tremors Dizzy Skin rash Wheezing

Y N spells Y N Boils Y N Cough - productive / dry

Y N Numbness/tingling Y N Itching Y N Shortness of breath

Y N Weakness Y N Moles Y N Snoring

Y N Hair Loss Y N Blood in sputum

Y N Bruising

Other Other Other

NEW PATIENT ADMISSION ASSESSMENT AND HISTORY

Name: Date of Birth:

Learning Assessment

Patient's primary language:

A hospital interpreter is needed.

The primary person(s) to be taught are:

Patient Family: Other: Phone:

Possible obstacles to learning: Speech Hearing Vision Physical limitations Cognitive limitations

What is the easiest way for you to learn? Listening Reading Pictures/Video Demonstration

Do you have any cultural or religious beliefs or practices that may impact your healthcare decisions? No Yes

If yes, please explain:

Signature of person completing this form Relationship to Patient Date

For Office Use Only

Learning Assessment: Goals of Learning Assessment: Patient and/or significant other(s) will verbalize understanding and

return accurate demonstration or verbalization of the following when applicable:

1. Safe and effective use of medications; including food/drug interactions. 2. Safe and effective use of medical equipment received from the Senior Health Clinic. 3. Knowledge necessary to restore/maintain/improve health.

Nursing assessment of knowledge base: None Limited Good Comprehensive

Recommendations to facilitate teaching:

None identified Recommendations:

Abuse/Neglect Screening: Does patient exhibit signs of abuse and/or neglect: No Yes

Comments:

Acknowledgement: I have reviewed this Admission Assessment & History in its entirety, including: Allergies, Medications, Current/Past Illnesses, Surgical History, Family and Social History, Review of Systems, Learning Assessment, and Abuse/Neglect Screening.

Signature & Title: Date:

MY MEDICATION / ALLERGY LIST

Name: Date of Birth:

Local Pharmacy name: Phone number:

Mail Order Pharmacy name: Phone number:

Write all prescriptions, over-the-counter medicines and supplements below.

Medication Name How much do I take at each dose?

When and how do I take it?

Why do I take it?

Example: Naproxen 1 tablet, 250 mg 7AM and 7PM, with food Arthritis

Please list all known food and drug allergies and the reaction. NO KNOWN ALLERGIES

MEDICATION/FOOD REACTION