NCMG Patient Information

NCMG Patient Information
Name*

First NameMiddle NameLast NameSuffix
Birthdate

MonthDayYear
Date
Home phone number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
Select one:

MinorSingleMarriedDivorcedWidowedSeparatedOther
Parent/Guardian's Name

First NameLast Name
Relationship
Parent/Guardian's Employer
Work Number
Please enter a valid phone number.
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Insurance Information
Name of Insured

PrefixFirst NameMiddle NameLast Name
Relationship
SSN
Name of Insurance
ID Number
Group Number
Union/Local Number
Additional Insurance Information*

YesNo
Name of Insured

First NameMiddle NameLast NameSuffix
Relationship
SSN
Name of Insurance
ID Number
Group Number
Union/Local Number
Authorization to release information:

I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released nor or in the future.
Authorization to pay Benefits to Physician: I hereby authorized and direct my insurance company to pay North Clark Medical Group any medical benefits which would be payable to me for their services.
I understand I am financially responsible for the charges not covered by this authorization.
Authorization for Medical Treatment: I authorize you to give me reasonable and proper medical care by today’s standards.
Patient Signature

Clear
Date

MonthDayYear
Date

Contact Info
The best way to reach me is my:

Home NumberCell NumberWork NumberEmail Address
Number
Please enter a valid phone number.
Email
example@example.com

Power of Attorney
I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment or coverage of these services.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
If applicable, legal representatives sign below:

By signing this form, I acknowledge that I am the legal representative of the member identified above and will provide written proof (e.g. Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the member’s behalf with respect to this authorization form.
Name of Legal Representative

First NameLast Name
Signature of Legal Representative

Clear
Date

MonthDayYear
Date

Controlled Substance Prescription Contract
Controlled substances are medications that have some potential for abuse or dependence. If not used properly they can cause serious medical problems and if sold for street use they contribute to addiction and crime. North Clark Medical Group MUST manage these medications in ways that are medically appropriate and comply with all Federal and State regulations. Please read the following carefully.

By signing, you agree to follow every stipulation of the contract. Exceptions cannot be made.
Controlled substances are habit forming and can cause physical dependence. Suddenly stopping the medication may cause physical withdrawal symptoms. These symptoms may include flu-like feelings, crawling skin, sleeplessness, irritability, anxiety and even seizures. I understand that I may develop physical dependence from medications.*
Initial
Patients with a history of substance abuse, including alcoholism, are at high risk of relapse from certain medications, Patients with a strong family history of substance abuse are also at a high risk for addiction. I understand and agree that I have notified North Clark Medical Group of any personal or family history of substance abuse, including alcohol abuse.*
initial
I understand that my medications may not be taken more often than prescribed. If you medication is not controlling your symptoms, you must schedule a follow up appointment. You cannot increase your dose. Prescription refills will not be given early under any circumstance. Travel plans during your regular refill appointment time will not result in early refills so please plan accordingly. I understand that if I run out of my medication, I may suffer withdrawal symptoms.*
initial
Obtaining controlled medications from more than one doctor without notifying all physicians who prescribe to you is a felony. The only exception is medication taken during an inpatient hospitalization. You must immediately notify us during your next appointment if you receive pain medications, sleeping pills, tranquilizers, or other controlled medications from any other provider (including emergency room doctors). I understand that I will be dismissed from the practice if I do not notify North Clark Medical Group that I have received controlled medications from another source.*
initial
Patients are responsible for scheduling and keeping all appointments. I understand that to get refills, I must be seen in the office and that no refills or medication changes will be made after hours or on the weekends.*
initial
I understand that I am receiving medications that are at a high risk of being stolen. I am responsible for protecting these medications and understand that North Clark Medical Group cannot replace medications that are lost, stolen, or damaged. We also recommend that you file a theft report with local law enforcement agencies.*
initial
I understand that selling, trading, or giving my medications to anyone is illegal.*
initial
I understand that it is the policy of North Clark Medical Group to perform urine or serum drug test during office visits and randomly at will. I understand that if I refuse or fail to provide a urine sample, I will not be prescribed my controlled medications. I also understand that should North Clark Medical Group become aware during testing that I am using street or prescription drugs not prescribed to me that it will result in loss of medical treatment with a controlled substance.*
initial
I understand that it is the policy of North Clark Medical Group to perform random pill counts. I will maintain an active phone number as well as answer and return any missed calls from North Clark Medical Group immediately. I will notify the office within 24 hours with any changes to my phone number. When called in for a pill count, I understand that I have 24 hours to arrive to the office with my medication in the original pharmacy container with the label intact. Failure to return multiple calls from our office, maintain an active number where you can be reached, or to appear for pill counts will result in loss of medical treatment with a controlled substance.*
initial
I understand that changing the date, quantity, or strength of a medication or altering a prescription in any way is illegal. This includes forging a prescription or provider signature. Our office cooperates fully with local law enforcement and the DEA. Any violation to these laws will result in immediate dismissal from the practice and may be reported to the authorities and local pharmacies.*
initial
I understand that my provider will use his or her medical judgment when deciding what medications to prescribe for my medical care and he or she may choose at any time to change medications, reduce dosage, or stop prescribing a controlled substance if he or she believes it is medically appropriate. Additionally, if I violate this contract, North Clark Medical Group must consider that I may be abusing or selling medications. IN such instances, doctor-patient confidentiality does not prevent North Clark Medical Group from providing pertinent information to law enforcement agencies. *
initial
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Office Policy for Missed or No Show Appointments
In order to better serve our patients we have implemented an office policy regarding missed appointments. Your health is important to us and we hope to see you on your scheduled appointment. Our doctors have busy schedules with many people who need appointments. If you find that you are unable to keep your scheduled appointment, we request that you cancel or reschedule at least 24 hours in advanced.

Missed appointment or appointments not cancelled within 24 hours of the appointment will be charged a no show fee of $20.00, which must be paid before the patient may be seen again. Missed counseling appointments or counseling appointment not cancelled within 24 hours will be charged a no show fee of $50.00, which must be paid before the patient may be seen again.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Patient Financial Responsibility Policy
Thank you for choosing North Clark Medical Group Practice to serve the health care needs for you and your family. We are pleased to participate in your health care and look forward to establishing a lasting relationship as your health care provider. As part of this relationship, we have outlined our expectations for your financial responsibility in our Patient Financial Responsibility Policy. Please read this document thoroughly.

Insurance Policy:
- It is important for you to be an informed consumer who understands the specifications of your insurance policy (e.g., vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiographs, laboratory tests, urgent care facility care). Your health insurance policy is a contract between you and your Health Insurance Company or employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations and limits on the outpatient charges regardless of whether or not our physicians participate in your plan.
- You must present a current insurance care at each visit. As a courtesy to you, we will bill your insurance company directly for medical services rendered. If problems arise regarding coverage issues, we will attempt to work with your insurance to help resolve them prior to making it your responsibility. However, please be advised that you are nevertheless ultimately financially responsible for payment of medical services rendered.
- If you do not present a current insurance care, you will be responsible for payment at the time of your visit. You will receive reimbursement from North Clark Medical Group if your insurance pays the claim at a later date.
  If you insurance carrier is not one with which we participate, you are responsible for payment in full.
- Insurance plans and Medicare consider some services to be “non-covered,” in which case you are responsible for payment in full.
  Accordingly, insurers are required to pay a properly submitted claim within 45 days. You have a responsibility to provide information to our office so a claim can be properly submitted. If your insurance company has not paid a claim on your behalf within 90 days, the balance will be transferred to your account and you will be responsible for payment. If we receive payment at a later date, you will be reimbursed.
- If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, our-of-pocket fees and coverage limits.
- North Clark Medical Group contracts with many insurance plans. Before you appointment, please be sure your doctor is in-network and the services are covered under your plan, If you doctor is out-of-network, you may be responsible for a higher co-pay and/or deductible or you may be billed for the cost of care.
- If we contact your insurance carrier regarding benefits or authorization on your behalf, we are not responsible for inaccurate information provided to us by your carrier. The information about your plan that we relay to you is in good faith and represents what the carrier has shared with us.
Address Change:
- It is important that we have your correct address information on file, please advise us anytime there is any change to your address, telephone or other contact information. We mail out lab results, pathology and appointment information in addition to billing statements to the address we have on file.
Co-payments, Deductibles and Co-Insurance:
- Co-payments are collected at the time of your visit at check-in. Insurance deductibles and fees for services nor covered by your insurance policy, if known, are due at the time the service is rendered, We accept cash, check and most major credit cards.
Billing:
- If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on a monthly basis. Payment is expected within 10 days of receipt of your statement.
Failure to Pay:
- Patient who ignore collection notices and fail to pay their balance risk negative credit ratings and possible dismissal from the practice
- Past Due accounts may hinder your ability to have appointments scheduled.
- Should your account balance become uncollectible or if you file bankruptcy, we will continue to see you on an emergency basis only for 30 days, giving you time to find a new source of medical care.
Fees:
- Returned checks are subject to a $25 fee and your account will be placed on a “cash-only basis.” We will accept payments only by cash or credit card until the balance is cleared.
- Failure to give 24 cancellation notice or failure to keep your scheduled appointment may result in a charge of $20 for doctors’ appointment and $50 for counseling. Missed appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. We reserve the right to charge to charge a fee for canceled or missed appointments. If you must cancel an appointment, North Clark Medical Group requires a minimum of 24 hours notice.
- There is an administrative fee for completing forms such as DMV, physical forms, FMLA, leave of absence, disability etc. Most forms require 5 to 7 working days to research your information and completed the form.
  There may be additional charges applied to your account if we are asked to copy medical records per patient request or participate in a Deposition or Phone Consultation on your behalf.
Guarantor:
- Any patient over the age of 18, or an emancipated minor, will be held financially responsible for all charges incurred. If another party is responsible for payment of your account, you must pay your balance in full and negotiate repayment with them outside of our office. This policy includes negotiating divorce agreements.
Medicare Patients:
- Medicare may not cover some of the services that your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully.
Minors and Dependents:
- Parents and guardians are responsible for payments for the dependents at the time services are rendered. Minors and dependents must present a valid insurance card at each visit if a claim is to be filed. The accompanying parent or adult is responsible for full payment at the time of service, In cases of divorce, please do not place our office in the middle of marital disputes, It is your responsibility to work out the payment of your child’s medical care between the custodial and noncustodial parent.
Non-Emergency Appointments:
- Outstanding balances or failure to pay co-payments upon check-in may result in physicals and other routine or screening appointment to be rescheduled.
Prompt Payment:
- Just as we make every effort to accommodate you when you are in need to medical care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office.
Referrals and Authorizations:
- Please be aware of and provide any required referrals or authorization in advanced of the appointment of service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt contact your plan directly for clarification.
Refunds:
- A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our office
Self-Pay Patients:
- Self-Pay patient should be prepared to pay at the time of each visit.
Worker’s Compensation:
- The patient must provide at time of service: a claim number, name of the carrier, the date of injury, employer at time of injury and name and number of the claim adjuster. Without this information, the patient will be held responsible for all charges, and payment will be collected at time of service.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

North Clark Medical Group

1802 E. 10th St

Jeffersonville, IN 47130

Phone: (812) 288-2488

Fax: (812) 288-6603
HIPAA Release of Information Authorization Form

North Clark Medical Group herein know as NCMG
I hereby authorize NCMG and its affiliates, employees, and agents to release information to:

SpouseFamilyOtherInformation is NOT to be released to anyone.
Spouse
Family
Other
My or my legal dependents person health information is maintained by NCMG (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, member ID number) except the following information:
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

North Clark Medical Group

1802 E. 10th St

Jeffersonville, IN 47130

Phone: (812) 288-2488 Fax: (812) 288-6603
Authorization for Release of Information
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Preferred Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize North Clark Medical Group to disclose my medical records to:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I authorized North Clark Medical Group to obtain my medical records from:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released prior to the written revocation. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to consent under my policy. Unless otherwise revoked, this authorization will expire on the below date. If I fail to provide an expiration date, this authorization will expire in 60 days from date of signature.

MonthDayYear
Date
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Witness name

First NameLast Name
Witness Signature

Clear

Notice of Privacy Practices

North Clark Medical Group
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully!

Protected health information about you is maintained as a record of you contacts or visits for healthcare services with our clinics. Specifically, “protected health information” is information about you, including name, address, phone, etc. that may identify you and relates to your past, present or future physical health condition and related health care services.

We are required to follow specific rules on maintaining the confidentiality of your protected health information, using your information, and disclosing or sharing this information with other health care professionals involved in your care and treatment. This notice describes your rights to access and control your protected health information. It also describes how we follow applicable rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our health care operations and of other purposes that are permitted or required by law. If you have any questions about this notice, please contact our Account Representative.

Your Rights Under the Privacy Rule

Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practice
- We are required to follow the terms of this notice, We reserve the right to change the terms of our notice at any time, If needed, new versions of this notice will be effective for all protected health information that we maintain at that time, Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.
You have the right to authorize other use and disclosure
- You have the right to authorize or deny any other use or disclosure of protected health information that is not specified within this notice, You may revoke an authorization, at any time, in writing, except to the extent that your health care provider or our office has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to designate a personal representative
- You may designate a person with the delegated authority to consent to or authorize the use of disclosure of protected health information.
You have the right to inspect and copy your protected health information
- You may inspect and obtain a copy of protected health information about you that is contained in your patient records.
You have the right to request a restriction of your protected health information
- You may ask us, in writing, not to use or disclose and part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care for notification purposes as described in the Notice of Privacy Practices, in certain cases, we may deny your request for a restriction.
You have the right to request an amendment to your protected health information
- You may request an amendment of your protected health information for as long as we maintain this information. In certain cases, we may deny your request for an amendment. You have the right to request disclosure accountability. You may request a listing of disclosures that we have made of your protected health information to entities or persons outside of our office other than for the purposes of treatment, payment, health care operations, or a purpose authorized by you.
How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health care information that we are permitted to make.

Treatment
- We may use and disclose your protected health information to provide, coordinate, or manage you health care and any related services, This includes the coordination or management of your health care with a third party that is involved in your care and treatment, We may disclose protected health information to other healthcare providers who may be involved in your care and treatment, We may also call you by name in the waiting room when your health care provider is ready to see you. We may use or disclose your protected health information as necessary to contact you to remind you or your appointment. We may contact you by phone or other means to provide results from exams or treatments and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health related benefits and services offered by your office.
Payment
- Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Healthcare Operations
- We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. This includes, but is not limited to, business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions, It also included education, provider credentialing, certification, underwriting, rating, or other insurance related activities. Additionally, It includes business administrative activities such as customer service, compliance with privacy requirements, internal grievance procedures, due diligence in connection with the sale r transfer of assets, and creating de-identified information.
Other Permitted and Required Uses and Disclosures

We may so use and disclose your protected health information in the following instance as outlined below. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.

To others involved in your healthcare
- Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, general condition or death. If you are not present or able to agree or object to the use of disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
As Required by Law
- We may use or disclose your protected health information to the extent that the law requires the use or disclosure.
For Public Health
- We may use or disclose your protected health information for public health activities and purposes to a health authority that is permitted by law to collect or receive the information.
For Communicable Diseases
- We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
For Health Oversight
- We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.
In Cases of Abuse or Neglect
- We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made in a manner that is consistent with the requirement of applicable federal and state laws.
To the food and Drug Administration
- Products: to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
For Legal Proceedings
- We may disclose protected health information in the course of any judicial or administrative proceedings, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). In certain conditions in response to a subpoena, discovery request or other lawful process.
To Law Enforcement
- We may also disclose protected health information as long as applicable legal requirements are met for law enforcement purposes.
In Cases of Criminal Activity
- Consistent with applicable federal and state laws, we may disclose protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend and individual.
For Military Activity and National Security
- When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel: 1) for activities deemed necessary by appropriate military command authorities: 2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or 3) to foreign military authority if you are a member of that foreign military service.
For Worker’s Compensation
- We may disclose your protected health information, as authorized to comply with worker’s compensations laws and other similar legally established programs.
When an inmate
- We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you
Required Uses and Disclosures
- Under the law, we must disclosures about you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.
Complaints
- You may address complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Risk Management and Compliance Department.

Notice of Privacy Practices Acknowledgement Form

North Clark Medical Group
Our Notice of Privacy Practices provides information about how we may use and/or release your health information. You have the right to review our notice before signing this consent. You also have the right to refuse to sign this consent
Patient Name

First NameLast Name
Patient Signature

Clear
Date

MonthDayYear
Date
If applicable:

For the patient's legal representative
Representative Name

First NameLast Name
Representative Signature

Clear
Date

MonthDayYear
Date

	Age	State of Health	Age at Death	Cause of Death
Mother
Father
Brother
Brother
Brother
Sister
Sister
Sister

NCMG Patient Information

Emergency Contact Information

Insurance Information

Contact Info

Power of Attorney

Controlled Substance Prescription Contract

Office Policy for Missed or No Show Appointments

Patient Financial Responsibility Policy

HIPAA Release of Information Authorization Form

Authorization for Release of Information

I authorize North Clark Medical Group to disclose my medical records to:

I authorized North Clark Medical Group to obtain my medical records from:

Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement Form

If applicable:

Health History

Symptoms Check

Conditions

Habits

Current Medications (Include over the counter medications)

Please state if any of your blood relatives have/had the following:

I certify that the above informationChemical Dependency is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any error or omissions that I may have made in completion of this form.

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	Year	Hospital	Reason for Hospitalization and Outcome
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	Serious Illness/Injuries	Date	Outcome/Long-term Effect
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	Year of birth	Sex	Complications if Any
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