New Patient Form

Internal Medicine Associates of Lincoln Park

Dr. Anju Budhwani
General Patient Information
Patient Name*

PrefixFirst NameLast Name
Nickname or preferred name:
Date of Birth*

MonthDayYear
Cell Number*
Home Number
Preferred Phone Number

CellHome
How do you prefer we remind you of your upcoming appointments?*

TextPhone CallOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Gender
Patient Height
Patient Weight
Patient Ethnicity*
Patient E-Mail*
example@example.com
License/ID Card

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Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone:*
What brings you in to our office?

SleepPulmonaryPrimary Care
Please describe what issues bring you in today. Include any signs or symptoms, as well as approximate time period present.*
How did you find our office?
Insurance Subscriber Information
Subscriber's Name (if not patient)

First NameLast Name
Relation to Insurance Subscriber:*

SelfSpouseDependent (child)Other
Subscriber Date of Birth (If Not Patient)*

MonthDayYear
Insurance Information
Primary Insurance Company*
Plan Name:
Primary Insurance Company Address: (this will be a PO Box on the back of the card or will say submit to your local insurance)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Member ID*
Primary Insurance Group Number:
Insurance Card - FRONT

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Insurance Card - BACK

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Secondary Insurance Information

If applicable
Secondary Insurance Company
Secondary Insurance Company Address: (this will be a PO Box on the back of the card or will say submit to your local insurance)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member ID Number:
Group Number:
Insurance Card - FRONT

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Insurance Card - BACK

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Patient Medical History
I have no medical history
Cardiology

Atrial FibrillationArrhythmiaCongestive Heart Failure (CHF)Coronary Artery Disease (CAD)Heart AttackHigh Cholesterol (Hyperlipidemia)High Blood Pressure (Hypertension)Heart Valves/StentsPacemaker/DefibrillatorOther
Endocrinology

Diabetes - Type OneDiabetes - Type TwoThyroid DiseasePrediabetesOther
Gastroenterology

Diverticulitis/osisGERD/HeartburnHepatitis/Liver DiseaseStomach UlcersPancreatic DiseaseOther
Neurology

MigrainesPeripheral NeuropathySeizuresStrokeTIAOther
Oncology (Cancers)

Cancer - BreastCancer - ColonCancer - LungCancer - ProstateCancer - SkinCancer - Other/Not ListedOther
Pulmonary

AsthmaAtelectasisBronchitisCOPDEmphysemaNodule(s)Oxygen DependencePneumoniaPulmonary FibrosisOther
Psychology

AnxietyBipolarDepressionSchizophreniaOther
Rheumatology

Arthritis (General)Autoimmune DiseaseFibromyalgiaRheumatoid ArthritisOther
Sleep

NarcolepsySleep Apnea - CPAP UseSleep Apnea - No CPAP UseOther
Please list any drug allergies (if none, please click "I have no known allergies, below)
Other Allergies: (if none, please click "I have no known allergies, below)
OR

I have no known allergies
Please list any surgeries and approximate date of each.
Please list any family history (medical history of biological family)*
Please list your current medications (with DOSAGE and # of times per day)
Please make sure your have put the dosage of all medications.
Please list any over the counter medications or supplements you take (including DOSAGE)
Please make sure your have put the dosage of all medications.
OR

I take no medications at this time
Pharmacy Name:
Pharmacy Address

Street Address

Street Address Line 2

CityState

Zip Code
Do you have a health care proxy/living will?

YesNo
Doctors
Primary Care Doctor:
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cardiologist:
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Doctor & Specialty
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Healthy & Unhealthy Habits
Exercise - 30+ minutes daily

Never/Not typically1-2 days/week3-4 days/week5+ days/week
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day1-2 glasses/week3-4 glasses/week5+glasses/week
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you CURRENTLY smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Are you a PAST smoker?*

NoYes, 0-1 pack/dayYes, 1-2 packs/dayYes, 2+ packs/day
If you have quit smoking, what year did you quit?
If you are, or have ever been a smoker, for how long have you/did you smoke?
Do you vape, or chew tobacco?

YesNo
Do you use illicit drugs, including marijuana?

YesNo
Social History
Occupation
Employer
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Number of Children & Ages of Children
Type a question
Any past labwork, scans, etc. the doctor may need for your visit:

Upload multiple files, if necessary.
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PLEASE BRING A HARDCOPY OF YOUR INSURANCE AND ID WITH YOU TO YOUR VISIT.

We ask that you upload a copy of each on this form so we can prepare your chart and verify identification. If you cannot produce a hardcopy of the insurance card, please email kim@DrBudhwani.com, with a photo of the front and back of the card.

Please be aware that it will be the patient's responsibility to verify with insurance the doctor is in network and what the copay, liability, or responsibility for the visit will be.
Consent to Treat: I the undersignsed, voluntarily consent to and authorize Internal Medicine Associates of Lincoln Park through its physicans, employees, and/or agents to provide such medical care and examinations, on a continuing basis, and to administer such routine diagnostic, radiological, and/or therapeutic procedures, tests, and treatments as are considered necessary or advisable, in my diagnosis, care and treatment, in the judgment of my physician included but not limited to collecting and testing bodily fluids, and administration of pharmaceutical products. I acknowledge that no guarantees have been made to me about the results of any examination or treatment.
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 Internal Medicine Associates of Lincoln Park to release any information required to process my claims.
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Internal Medicine Associates of Lincoln Park

General Patient Information

Insurance Subscriber Information

Insurance Information

Secondary Insurance Information

Patient Medical History

Doctors

Healthy & Unhealthy Habits

Social History