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First Name:

Last Name:

Gender:
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Phone Number 1:

Phone Number 2:

Text Number 1:

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How much Info we should leave by Voice Mail :
Only callbackFull Detail

How much Info we should leave by Text Message :
Only callbackFull Detail

E-Mail (we may send full info) :

Preferred Contact Method:
VoiceTextEmail

Emergency Contact Info:
Emergency Contact Name
Emergency Contact Phone:
Emergency Contact Relationship: SiblingParentChildfamilyfriendlegal Guardian

Persons allowed access to your health info:
Only In ER: YES
First Person We can disclose Info to:
Second Person We can disclose Info to:

Insurance:

Insuance Company1:
Insuance Policy 1:
Insurance Company 2:
Insurance Policy 2:

Medical Problems:
High-Blood-PressureHeart-ProblemsChest-PainsDiabetesIrregular Heart BeatsLoss of consciousnessJoint PainsDepression/AnxietyHigh blood pressure /HypertensionHeart diseaseHeart attackDiabeteschest painsHeart FailureIrregular Heart beatA-Fib (atrial fibrillation)Passing out (loss of consciousness)Shortness of breathEmphysemaCOPDAsthmaCancerDepressionAnxietyFibromyalgiaBack painNeck painLeg crampsBurning sensation in legs feet armsSkipped heart beatsAllergies seasonalSinus problemsHepatitis C“ “ CirrhosisDiarrheaConstipationHemorrhoidsFemale bleedingBlood in bowel movementNose bleedsThyroid problemsAneurysmsStrokeNumbness tinglingNeuropathyVision problemsHearing problemsBalance problemsSeizuresDizzinessAnemiaBlood thinner useHeadaches or MigrainesGlaucomaAbdominal (belly) painPolypsUrine InfectionsSleep problems (insomnia)Weight changes (gain or loss)Osteoporosis (bone loss or thinning)FracturesFallsSkin rashLupusJoint Pains / swellingNausea / vomitingWell visit - New InsuranceNo Known Medical ProblemsOther - will discuss on face face Visit

Surgical History:
Heart Bypass surgeryPacemaker placementDefibrillator placementValve ReplacementAneurysms repairBrain surgeryCataract removalGlaucomaAdenoidsTonsilsBelly AneurysmsHerniaColostomy bagGall bladderAppendixBreast biopsyKidney stonesKidney removalHemorrhoidsBreast surgeryHysterectomyOvary removalStents (abdominal legs )Stents (heart)Artery Bypass legsBack surgeryNeck surgeryHip replacementKnee replacementBone graftsFracturesNONE

Day Surgery / Procedures:
BiopsyOrthoscopic knee examStomach ScopeColon ScopeMoles /skin tagsStents for heart arteriesStents belly or legsAngiogram / angioplastyNONE

Inatvie Medical Problems:
PneumoniaAsthmaKidney stonesUrine infectionsCancerBleedingFallsNONE

Allergies:
No Known Drug AllergiesAllergic (describe Bellow)

Tobacco:
Never SmokedFormer SmokerCurrent Smoker

Alcohol:
None1 drink per week1 drink per dayMore than 1 drink per dayI rather discuss in personSocially 1 per month at leastOccationaly (holiday,Xmas,birthdays)

Pharmacy Name:
Pharmacy Tel:
Fax:
Street: City:
State:

How did you hear about us?
FriendFamilyAnother DoctorYellow pagesNewspaper AdInsurance planClose to workRadioOnline reviews web Google

Policies:
I have read , understood and agree to the HIPPA, release of information, Billing , Appointments, Drug testing , Labs policy and procedure of the practice. I understand these policies may change and its my responsibility to request updates. I also understands that I can be discharged with 30 days notice. Info given is correct, any incorrect information may lead to inappropriate care and harm. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize DOCTOR IS IN, CORP / HASSAN FAROOQ, MD, or insurance company to release any information required processing my claims.

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