hinet.org - Health Summary

Health Summary
Name
DOB

MonthDayYear
Date
What is the reason for your visit?
Preferred Pharmacy
Primary Care Provider- Name, Office, and Phone Number
Your Symptoms
General

Excessive tirednessWeight gainWeight lossDifficulty sleepingFeverNight sweats
Eyes

Eye painVision abnormalityRednessDrynessIrritaion
Head

Hearing problemsWears hearing aidsSinus painHoarsenessPainful swallowingJaw pain
Cardiovascular

Chest painChest tightnessPalpitationsHeart murmurFast heart rateLeg cramps when walking
Respiratory

Breathless at restBreathless with exertionCoughExcessive snoringDifficulty taking deep breathsBreathing related sleep disorder
Gestrointestinal

HeartburnNauseaVomitingConstipationHemorrhoidsAbdominal painBlood in stoolBlack stool
Endocrinology

Heat intoleranceCold intoleranceAbnormal hair growthHair loss
Muscle and Bones

Joint painTendonitisBursitisFoot swellingAnkle swellingLimpBack painFoot trouble
Specify foot trouble
Nervous System

HeadachesDizzyLightheadedBad memoryFaintingSeizuresNumbnessUnsteady walking
Specify Numbness
Emotional

DepressionLoss of pleasureAnxietyIrritability and angerExcessive cryingMood swings
Blood

Easy bruisingExcessive bleedingSwollen lymph glandsOther
Skin

Changes in skin textureSkin lesionBreast or other lumps
Specify breast or other lumps
Allergies
List all allergies (food and medication)
Tobacco Use
Do you smoke?

YesNo
Have you ever smoked?

YesNo
How many cigarettes per day?
How long have you smoked?
What age were you when you quit?
Do you drink alcohol?

YesNo
What type of alcohol?
How many servings per month?
Past Medical History
Check all that apply

Asthma or lung diseaseHay fever/Other ENT diseaseHivesEczemaPneumoniaRheumatic FeverBursitisSciaticaLumbagoNephritis or other kidney diseaseGallbladder diseaseAnemia or other blood disorderJaunice or liver diseaseBladder infectionsBladder issueEpilepsyMigrainesTBHIVChronic InfectionDiabetes type 1Diabetes type 2CancerHigh blood pressureStrokeBlood clots/ThrombophlebitisColitis or other bowl diseaseStomach or other ulcersHyperHypothyroidismRectal diseaseAnxietyDepressionGlaucoma or other eye diseaseProstate or other urinary troublesHigh cholesterolLow bone densityAutoimmune disease
Specify Asthma or lung disease
Specify Hey fever/other ENT disease
Specify Nephritis or other kidney disease
Specify Jaunice or liver disease
Specify Chronic infection
Specify Cancer
Specify Colitis or other bowl disease
Specify Stomach or other ulcers
Specify Rectal disease
Specify Glaucoma or other eye disease
Specify Prostate or other urinary troubles
Specify Autoimmune disease
Other Serious disease or illness
Past Surgical History

Specify and include date which applies to you

	Yes	No	Specify	Date
Tonsillectomy
Appendectomy
Gallbladder removal
Heart surgery or stent
Cardiac Ablation
Hysterectomy
Total Radical
Vaginal
Eye surgery
Sleep removal
Bone or joint surgery
Hernia repair
Lung surgery
Other surgery

Family History

Which family member

	Yes	No	Family Member
Cancer
Tuberculosis
Diabetes
Heart disease
High blood pressure
Stroke
Osteoporosis
Suicide
Sudden death
Other

Social History
Do you exercise regularly?

YesNo
What type of exercise?
In the past year have you experienced any of the following?

MarriageDivorce or separationMajor illness or death in your familyPersonal illness or injuryGained a new family memberChange in job or home
Specify Personal illness or injury
Other specify
Screening tests
Date of your last colonoscopy or flex sig?

MonthDayYear
Date
Date of your last PSA(males only)?

MonthDayYear
Date
Date of last AAA screening ultrasound?

MonthDayYear
Date
Date of last carotid artery screening?

MonthDayYear
Date

Information Permission
The following authorization is valid until is revoked in writing.
If you would not like your health care discussed with anyone besides your primary care provider or the provider who referred you to our clinic, please check the box below.

Primary care provider/Referring provider only
If you wish for your health care to be discussed with any other persons, such as family members, please list them below.
I give permission to Mr. Bhola and or staff to discussed my health care with the following person or persons?
Signature

Clear
Date

MonthDayYear
Date
Witness

Notice of Privacy Practices Acknowledgment
We keep a record of the health care services we provide to you. You may ask to see a copy of that record at any time. You may also ask us to correct that record if there are any errors. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your medical records or get more information by contacting the practice administrator.

Our Notice of Privacy Practice decides in more detail how your health information may be used and disclosed and how you can access your records.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices.
Patient or legally authorized legal signature

Clear
Date

MonthDayYear
Date
Write name if signed on behalf of the patient
Date

MonthDayYear
Date

Financial Policy
Thank you for choosing us to provide your cardiology care.

We are committed to your treatment being successful. The following is a statement of our financial policy which we require you to read, initial, and sign prior to treatment.

*All patients must complete our patient information forms prior to seeing to provider in our clinic.
*Full payment of the portion not covered by your insurance company is expected.

Initials   Insurance
We are happy to submit your insurance claims, if you provide us with the necessary information. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. Our practice is committed to providing the best treatment possible for our patients and we charge what is usual and customary for our area. We do our best to estimate your balance owing before your insurance pays, but this is only an estimate, and not a guarantee.

Initials   Delinquent Accounts
We charge 1.5% interest after 60 days 18% APR. We also refer delinquent past due accounts to an outside collection agency. An account that is referred to a collection agency will result in termination of medical services from our office. We will be available, for your cardiology needs, for 30 days after the account is transferred to the collection agency while you seek another cardiologist.

Initials   Missed Appointments
We charge a missed appointment fee of $50 per missed appointment (Office visit, telehealth visit, diagnostic testing besides nuclear stress tests). We charge a missed appointment fee of $300 for nuclear stress tests. This is to cover the cover of the radioactive isotope that is ordered for the test. The fee of $300 will not be billed to your insurance company if you miss your appointment.

Refusing to initial or sign this form does not excuse you from financial responsibility for services provided to you.

If you are covered through the (VA), Care Medical Group, your employer (Fire Dept, Police Dept, etc) you are still required to sign this forms.

I have read, understand, and agree to the above financial policy.
Patient/Responsible Party Signature

Clear
Date

MonthDayYear
Date
Write Name
Should be Empty:

Health Summary

Your Symptoms

Allergies

Tobacco Use

Past Medical History

Past Surgical History

Family History

Social History

Screening tests

Information Permission

Notice of Privacy Practices Acknowledgment

Financial Policy