welcome to abington hematology oncology, · abington hematology oncology assoc. – new patient...
TRANSCRIPT
Welcome to Abington Hematology Oncology, Your appointment is scheduled for ____/______/_______at _______:_______ at the Holy Redeemer location, suite 1000. Please take a few minutes to complete all the enclosed forms and bring them to your appointment when you check in with the receptionist on that day. Please bring your insurance identification card or cards along with any necessary referrals that well apply If you have had recent blood work or scans, please bring copies of these studies to your appointment. If you do not have a copy, please call your doctor and request that they fax these studies to our office prior to your appointment. Our fax number is 215-947-1378 Our office is located at the Holy Redeemer Hospital at 1648 Huntingdon Pike, Suite 1000. Parking is available in the reserved parking spaces in the Betty Bott Cancer Center Parking Lot. If you have any problems with the enclosed forms, please arrive to your appointment approximately 15 minutes before your appointment to complete them. Should you have any questions please contact our office at 215-947-5460 We invite you to sign up for our SEE YOUR CHART WEB PORTAL, it is a free service provided by our practice. This allows you to view important medical information about your medical treatment and upcoming appointments. You are able to COMMUNICATE with the staff and your physician within a safe, secure environment and receive immediate feedback during office hours. It is also a way to share information with caregivers, adult children and physicians. - It is easy to use-simply, provide us your email information, our practice will send you and invite that will give you access. Log onto a computer with INTERNET access and go to: https://secure.seeyourchart.com. enter your assigned PIN, User name and password We invite you to visit our website at cancerpa.net. Here we provide forms to bring to your visits, access to our portal, and other information about our practice. Thank you for being a valuable part of our practice Sincerely, The physicians and staff at Abington Hematology Oncology Associates **Weather Policy: In case of inclement weather, our office may make adjustments to our office hours. changes to our office hours will be available on our phone line by 8am that day. Please call the day of your appointment for more information.
Abington Hematology Oncology Assoc. – NEW PATIENT Questionnaire
WELCOME TO OUR PRACTICE
PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.
Date:________________________ Name:_______________________________________ S.S.#______________________________________ EMAIL: ____________________________________________________________WE CAN SEND YOU AN INVITATION TO HAVE YOUR PRIVATE ACCESS TO YOUR PATIENT RECORDS ON OUR “SEE YOUR CHART” PORTAL: Marital Status: Married Single Other DOB:_____________ New Patient:________ RACE:____________________SEX:_____________PREFERRED LANGUAGE:____________________ Ethnicity: Non Hispanic or Non Latino: Y N Hispanic or Latino: Y N Address:__________________________________________________________________ ___________________________________________________________________ City, State_______________________________________________Zipcode______________ Home number:_____________________________________________________ Cell number:_______________________________________________________ Best contact number we can keep on file:___________________________________ Employed: Y N Occupation:___________________________ Emergency contacts:
NAME: RELATIONSHIP: CONTACT:
PAGE 1
Primary Insurance Carrier: • None
• NAME:__________________________________________________
• Primary Policy Effective Date:_____________________________________
Claims Address:______________________________________________________
• __________________________________________________________________________
• City, State______________________________________________________________
• Zip Code_______________________________________________________________
• Insurance Phone Number__________________________________________
• Primary Insurance ID #_____________________________________________
• Primary Group Policy #_____________________________________________
• Primary Group Name:_______________________________________________
• SUBSCRIBER: (state patient if Same as patient)________________________________
• Insured Name, Phone and DOB(if different from
patient)________________________________________________________________________________
Secondary Insurance Carrier: • None
• NAME:__________________________________________________
• Secondary Policy Effective Date:_____________________________________
Claims Address:______________________________________________________
• __________________________________________________________________________
• City, State______________________________________________________________
• Zip Code_______________________________________________________________
• Insurance Phone Number__________________________________________
• Secondary Insurance ID #_____________________________________________
• Secondary Group Policy #_____________________________________________
• Secondary Group Name:_______________________________________________
• SUBSCRIBER: (state patient if Same as patient)________________________________
• Insured Name, Phone and DOB(if different from
patient)________________________________________________________________________________
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PROVIDER INFORMATION:
REFERRING PHYSICIAN:________________________________________________________________
• PHONE NUMBER:________________________________________________________________________
• FAX NUMBER:____________________________________________________________________________
• ADDRESS_____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PRIMARY PHYSICIAN:________________________________________________________________ • PHONE NUMBER:________________________________________________________________________
• FAX NUMBER:____________________________________________________________________________
• ADDRESS_____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Which of your Medical Providers would you like to receive a letter from your Oncologist? Please provide as much information as possible: Name: Specialty Phone #: Address:
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Does anyone in your immediate family have Cancer?(Father, Mother,Brother, Sister, Children, Cousins, Uncles, Aunts) YES___________ NO_______ If yes please provide the below: Relationship to you: Type of Cancer Living? Y or N- If no, Date
of Death and Cause of Death
Do you have an Advanced Directive/Living Will? YES_______ NO________ Do you have Diabetes? YES________ NO________ Medical or Medication Allergies: Please list type of reaction and severity: __________________________________________________________________________________________________________________________________________________________________________________________________
REASON FOR YOUR VISIT: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAST MEDICAL HISTORY: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAST SURGICAL HISTORY: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PAGE 4
Social History: Have you ever smoked tobacco products?
No _____ Yes_____ (complete the following questions) a. Number of years smoked? _________ b. What type cigarettes, cigars, used snuff, or chew?
(circle) c. How much per
week? _______ d. Have you quit?............................ No ______ Yes_____
When _______ e. Do you want to quit?.................. No ______ Yes_____
Do you drink alcohol? No ______ Yes_____ (complete the following questions)
a. _______ beer per: day week month b. _______ glasses of wine
per: day week month c. _______ mixed drinks
per: day week month d. Any prior or current history of alcohol abuse? No Yes e. Do you want to quit? No ______ Yes_____
Do you use recreational drugs? No Yes (complete the following questions)
a. When did you start? _________ b. What type? _____________ c. How much per week? _________ d. Have you quit? Yes _______ No _______ e. Do you want to quit? No ______ Yes_____
Immunizations: Have you had the following? Flu shot:
• No ______
• Yes_____ If yes, when?___________________
Pneumonia shot: • No ______
• Yes_____ If yes, when?___________________
PAGE 5
Health Screening: Have you had the following? Mammogram
• No ______
• Yes_____ If yes, Date?___________________ BY WHOM__________________________
Colonoscopy • No ______
• Yes_____ If yes, Date?___________________ BY WHOM__________________________
PHARMACY AND MEDICATION UPDATE: * PHARMACY: Please provide as much information as possible. Please supply both local and mail order. Name: Phone: Address/ZIP CODE:
MEDICATIONS: Please list all medications include name, dose, and frequency Name: Dose: Frequency
PAGE 6
EMOTIONAL WELL BEING: Are you feeling depressed?
• NO________
• YES_______ , if yes please
explain:__________________________________________________________________________________
Falls
Have you had a fall since your last Office Visit • NO_______
• YES________
Do you use an ambulation device (wheelchair, walker, cane)? • NO_______
• YES________(If yes please circle the device used
Do you have fatigue? • NO_______
• YES________ If yes please answer:
IS IT: Relieved by rest?
• YES_______
• NO________
Not relieved by rest and impacts on your daily life? • YES_______
• NO________
Not relieved by rest and limits self-care? • YES_______
• NO________
Do you have any hearing loss? • NO_______
• YES________
IS IT BILATERAL? • NO_______
• YES_______
DO YOU HAVE A HEARING AID? YES________ NO_________ PAGE 7
Do you have any Mouth Sores? • NO_______
• YES_______please describe:
______________________________________________________________________________
Are you short of breath? • NO_______
• YES_______If yes please answer:
IS IT: Short of breath at rest:
• NO_______
• YES________
▪ Mild ____________
▪ Moderate __________
▪ Severe_________
Short of breath upon exertion only: • NO_______
• YES________
▪ Mild ____________
▪ Moderate __________
▪ Severe_________
Do you have a cough? • NO_______
• YES________
▪ Mild ____________
▪ Moderate __________
▪ Severe_________
Do you have any chest pain? • NO_______
• YES_______
If yes, do you have any arrhythmias? • NO_______
• YES_______
PAGE 8
Are you symptomatic? • NO_______
• YES_______
Is medical intervention needed? • NO_______
• YES_____
Do you have trouble swallowing? • NO_______
• YES_______
If yes, are you able to eat? • NO_______
• YES_______
If yes, is eating altered? ▪ NO_______
▪ YES_______
Do you have tube feedings? ▪ NO_______
▪ YES_______
Do you have Diarrhea? • NO_______
• YES_______
If yes how many episodes per day? _______ Are you using any anti-diarrheal?
• NO_______
• YES_______ what are you using? _______________________________________________
Do you have nausea? • NO__________
• YES_______ Do you have Loss of Appetite? NO_________ YES_______________
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Are you using an anti-nausea medication? • NO_______
• YES_______, Name and does it help?__________________________________
Does it help relieve the nausea? • NO_______
• YES_______
Is oral intake decreased? • NO_______
• YES______
Have you had weight loss? • NO_______
• YES______
Are you vomiting? • NO_______
• YES_____If yes, how often per day? ____________________________________________
Do you have Constipation? • NO_______
• YES_______ , Last BM?_______________
Are you using any stool softeners or laxatives? • NO_______
• YES________ NAME?_______________
Do You Have Pain
• NO_______
• YES_______ Location?____________________________When:____________________________
Please circle which describes the type of pain: Dull Burning Stabbing Achy Mild Discomforting Intense Unbearable Other, please describe______________________________________________________________ o Rate your pain on a scale of 1-10 (1 being least amount of pain, 5 moderate amount
of pain, 10 the worst pain you have ever had) Score:_____________
PAGE10
Do you have a Rash? • NO_______
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one)
Mild – covering < 10% of your body Moderate – covering 10 – 30% of your body Severe – covering > 30% of your body If yes please note location, if it is a raised rash, or if it is causing you to itch _________________________________________________________________________________________________
Do you have Myalgia? (Pain in your muscles) • NO________
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one)
Do you have Arthralgia? (Pain in your joints?)
• NO________
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one)
Do you have Motor Neuropathy (for example foot drop or leg/arm weakness)?
• NO________
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one)
Do you have Sensory Neuropathies?(for example tingling in your toes or fingers)
• NO________
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one)
Do you have hot flashes? • NO________
• YES_______ , If Yes is it Mild, Moderate, Severe? (please circle one) Are you
using any intervention?
▪ NO_______
▪ YES_______
• If yes, please let us know the intervention
______________________________________________________________________________________ PATIENT SIGNATURE:_____________________________________________________________
DATE:___________________________________________________________________
PAGE 11
AHOA AUTHORIZATION for RELEASE of INFORMATION to FAMILY MEMBERS
PATIENT NAME: DOB: Many of our patient’s allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family member indicated below. I authorize ABINGTON HEMATOLOGY ONCOLOGY to release my medical and/or billing information to the following individual(s):
1. ______________________relation to patient_________________ 2. ______________________relation to patient_________________ 3. ______________________relation to patient_________________
Patient Information:
*I understand I have the right to revoke this authorization
at any time and that I have the right to inspect or copy the
protected health information to be disclosed.
*I understand that information disclosed to any above
recipient is no longer protected by federal or state law and
may be subject to re disclosure by the above recipient.
*You have the right to revoke this consent in writing
Signature:______________________________________
Date:_________
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