Attune Health New Patient Request
Thank you for your interest in Attune Health!
For a faster response to scheduling, email newpatient@attunehealth.com
Tracking status
Sent response to provider
Approved by provider
Forwarded to AF Coordinator
Waiting for more patient info
Contacted pt, no response
Do not schedule/Difficult pt
Scheduled, Confirmation email needed
Complete
Denied
Spoke to PT, PT will call back
Patient Declined Alt Provider
Patient Declined AF
Declined - OON
Waiting to be Scheduled
Patient Declined
Provider Response
RSV
RSV AF
RSV JOINT
SP
SP AF
SP JOINT
MR
MR JOINT
MR AF
JA
JA Joint
JA AF
Name
*
First Name
Last name
Middle initial
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
I Would like to see:
*
Dr. Swamy Venuturupalli
Dr. Daphne Scaramangas
Dr. Mark Riley
Dr. Joseph Azzam
No Preference
Address
*
Address
Street Address Line 2
City
State
Postal / Zip Code
Insurance Information
**You will be required to present your ID and insurance cards at the time of your appointment**
Primary Insurance
*
Primary Insurance ID#
*
Primary Policy Holder Name
*
Primary Policy Holder DOB
*
Primary Policy Holder Relationship
*
Secondary Insurance
*
Secondary Insurance ID#
*
Secondary Policy Holder Name
*
Secondary Policy Holder DOB
*
Secondary Policy Holder Relationship
*
Referred to Attune Health by
*
Please provide full name of medical professional
Primary Care Physician / Internist
Please upload a copy of your insurance cards (front and back). This will help us run your benefits and go over your eligibility with our office.
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Why do you want to be seen at Attune Health?
What are you hoping to get from your visit?
Have you ever been diagnosed with a Rheumatologic or Autoimmune Disease by a medical professional?
Yes
No
If yes, what was the diagnosis
Name of provider who made the diagnosis
Have you seen a Rheumatologist in the past?
Yes
No
If yes, please list the provider(s)
What was the diagnoses given?
Please list the name of other practitioners you have seen for the current complaint
Please review and mark anything that applies to you
I've experienced dry eyes for 3 months or longer
I have a history of iritis and/or uvetitis
I've experienced dry mouth for 3 months or longer
I've had a lot of hair fall out recently
I get oral ulcers
I'm troubled by stiff or painful joints
My joints feel swollen from time to time
I have a history of bloody diarrhea
I have experienced chronic low back pain
I have recurring sinus infections
I'm troubled by double vision
I often get a rash on my cheeks
I'm sensitive to sunlight
My fingers turn different colors in cold weather? (Raynauds)
I've had pleurisy or pericarditis
I experience scalp tenderness
I experience pain or stiffness in my hips and/or shoulders
I've been told I have protein in my urine
I've had a positive ANA (antinuclear antibody) or any abnormal blood test?
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Review of Medications
Anti-Inflammatory/Pain Meds
Diclofenac
Celebrex
Mobic
Indocin
Advil
Naprosyn
Voltaren/Diclofenac
Prednisone
Rheumatic Biologics
Actemra
Cimzia
Enbrel
Humira
Orencia
Remicade
Rituxan
Simponi Aria
Benlysta
Stelara
Cosentyx/Taltz
Tremfya/ Skirizi
Disease Modifying Anti-Rheumatic Drugs (DMARD)
Arava (leflunomide)
Cytoxan
Xeljanz/Rinovaq
Otezla
Imuran (Azathioprine)
Methotrexate
Sulfasalazine (Azulfidine)
Plaquenil (Hydroxychloroquine)
Fibromyalgia Medications
Lyrica
Cymbalta
Savella
Gabapentin
Tramadol
Cyclobenzaprine (Flexiril)
Nortriptyline (Pamelor)
Amitriptyline/Elavil
Gout Medications
Colchine
Uloric
Kystexxa
Probonecid
Allopurional
Osteoporosis
Fosamax
Actonel
Boniva
Zoledronic Acid/Reclast
Prolia
Estrogen
Evista/Raloxifene
Forteo/Tymlos
Evenity
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Medication & Dose
Please list any medications you are currently on..
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Review Of Symptoms
CONSTITUTIONAL
Recent Weight Gain
Recent Weight Loss
Fatigue
Weakness
Fever
EYES
Pain
Redness
Loss of Vision
Double or Blurred Vision
Dryness
Feels like something in eye
Itching
EARS-NOSE-MOUTH-THROAT
Ringing in ears
Loss of hearing
Nosebleeds
Loss of Smell
Runny Nose
Sore tongue
Bleeding gums
Sores in mouth
Loss of taste
Dryness of mouth
Frequent sore throats
Difficulty swallowing
CARDIVASCULAR
Chest pain
Low blood pressure
Irregular heartbeat
Sudden changes in heart beat
High blood pressure
Swollen legs or feet
Heart murmur
RESPIRATORY
Shortness of Breath
Cough
Coughing of blood
Wheezing (asthma)
GASTROINTESTINAL
Nausea
Vomiting
Constipation
Persistent/frequent diarrhea
Blood in stool
Gas
Abdominal pain
Heartburn
GENITOURINARY
Difficult urination
Pain or burning on urination
Blood in urine
Cloudy "smokey" urine
Discharge from penis/vagina
Vaginal dryness
Rash/ulcers
Sexual difficulties
INTEGUMENTARY (SKIN &/OR BREAST)
Easy bruising
Rash
Hives
Sun sensitive (sun alergy)
Tightness
Nodules/bumps
Hair Loss
Color changes of hands or feet in cold
MUSCULOSKELETAL
Morning Stiffness
Joint pain
Muscle Weakness
Muscle tenderness
Joint swelling
How long does your morning stiffness last
NEUROLOGICAL SYSTEM
Headaches
Dizziness
Muscle spasm
Sensitivity or pain of hand and/or feet
Memory loss
Night sweats
PSYCHIATRIC
Anxiety
Depression
Difficulty falling asleep
Difficulty staying asleep
HEMATOLOGIC/LYMPHATIC/IMMUNOLOGIC
Swollen glands
Tender glands
Anemia
Bleeding tendency
Frequent sneezing
Increased susceptibility to infection
Blood tranfusions
List any blood transfusions
ENDOCRINE
Excessive thirst
Date of Last Mammogram
Date of Last Eye Exam
Date of Last Chest X Ray
Date of Last TB Test
Date of Last Bone Density
Please submit any additional reports, labs, imaging reports, etc. that you feel will be helpful to the provider
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