twinsburgmed.com - Annual Physical For Male

New Patient Information Form
Full Name*

First NameLast Name
Soc. Security #*
DOB *

MonthDayYear
Date
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone*
Please enter a valid phone number.
E-Mail Address*
example@example.com
Sex:*

MaleFemaleOther
Marital Status:*

SingleMarriedWidowedDivorced
Race:*
Height:*
ft & in
Weight:*
lbs
Occupation:
Employer:*
Emergency Contact Name:*
Relationship:*
Phone Number
Please enter a valid phone number.
Primary Care Physician name:
Date Last Saw PCP?

MonthDayYear
Date
Last Annual Physical?
Preferred Pharmacy?
Consent to leave confidential information by phone, text, email, mail, or voicemail containing detailed medical information on the phone number(s) provided. This information may include, but not limited to, demographic information (partial or full name, date of birth, address, etc.), billing information, medical information (diagnosis, medications, test results, etc.). *

YesNo
Medical Questions
Tobacco Use?*

YesNoQuit
Years used?
what year quit?
Packs per day?
Alcohol Use?*

YesNo
How often?
Illicit/Recreational Drug use?*

YesNo
What Kind?
How often?
Diabetic?*

YesNo
If yes: Year diagnosed?
Last A1C?
Last Diabetic Foot Check date?

MonthDayYear
Date
Name of Doctor who manages your diabetes:
Date last seen:

MonthDayYear
Date
Women: Are you.....
Pregnant/Trying to get pregnant?

YesNo
Taking oral contraceptives

YesNo
Nursing

YesNo
Are you allergic to any of the following?*

None AspirinPenicillinCodeineLocal AnestheticsAcrylicMetalLatexSulfa DrugsOther
If other, please explain:
Information of Insurance Policy Holder

(if self, skip section)
Name
DOB

MonthDayYear
Date
Relationship
Phone Number
Please enter a valid phone number.
Address (if Different than Above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Medical Diagnosis History:

NONE
Medications:

NONE
Surgical History

NONE
Surgical History (Please list all previous surgeries and the year they occurred.)*
Family History

NONE
Family History *
How would you describe your OVERALL HEALTH:*

ExcellentFairPoor
Ever been hospitalized?*

YesNo
Is so, what for and what year?
Any implantable devices?*

YesNo
Year implanted?
Do you have any concerns regarding SAFETY at home?*

YesNo
If yes, explain:*
Household smoke detector?*

YesNo
Firearms in home?*

YesNo
If yes, are they locked in a safe place?

YesNo
What gender or pronoun you identify as?
In a relationship?

YesNo
For a relationship, I prefer:

MaleFemaleBothOther
Sexually active?

YesNo
Pregnant or Trying to get pregnant?

YesNo
Breastfeeding?

YesNo
Any form of contraception (including hysterectomy & vasectomy)?

YesNo
Type:
Describe OVERALL DIET: *

Well-balancedTypical American DietVegetarian/VeganOther
Regular EXERCISE ROUTINE?:*

YesNo
Daily Hours of SLEEP: *
WATER ounces daily: *
Do you consume CAFFEINE?*

YesNo
If yes, how often?
Do you consume JUICE OR SODA?*

YesNo
If yes, how often?
Have you seen a dermatologist for a yearly skin exam?
Last date & dermatologist office name
In the last year visited:
DENTIST? *

YesNo
EYE DOCTOR? *

YesNo
OTHER MEDICAL PROVIDERS? If so, list name and specialty?
Do you have an ADVANCED DIRECTIVE/LIVING WILL/DPOA on file?*

YesNo
History of HIGH CHOLESTEROL?*

YesNo
Ever been treated for it?*

YesNo
History of HIGH BLOOD PRESSURE? *

YesNo
Ever been treated for it?*

YesNo
History of DIABETES or PREDIABETES? *

YesNo
Ever been treated for it?*

YesNo
Feeling down, depressed or hopeless?*

YesNo
Have you lost interest or pleasure in doing things?*

YesNo
Check if you have completed the following vaccines:*

childhood vaccinesinfluenzatetanus (within last 10 years)shinglespneumoniacovidcovid boosterNone
Covid

ModernaPfizerJ&JOther
Covid Booster

ModernaPfizerJ&JOther
None: Reasoning
Would you like STD screening (mainly for Gonorrhea, Chlamydia, Syphilis, or HIV)? *

YesNo
History of being tested for HEPATITIS or exposure to someone with hepatitis?*

YesNo
Have you ever been screened for lung cancer by a low dose CT-scan? *

YesNo
If yes, results?
Have you completed a colonoscopy in the past?*

YesNo
Year?
Abnormal?
FOR MALES ONLY:
Ever been screened for prostate cancer?

YesNo
Year?
Abnormal?
Ever been screened for an abdominal aortic aneurysm?

YesNo
Year?
Abnormal?

Office Policies
Referral Process
It may be necessary for our office to refer you to a specialist to manage your care. In order for a referral to be made, you must be evaluated first in our office. If you need to request a referral from us, phone us at least one week prior to your appointment. As part of the referral process, we may need to share your medical information with another provider or specialist. Your privacy is protected as only minimal information is shared.

Medication Refills
Please bring your medications to your appointments. Should you need refills prior to your next appointment, first call your pharmacy. They can request a refill from our office. Please give us at least 1 week notice prior to your medication running out, 2 weeks’ notice if it is a mail-order pharmacy. Pain medicines may require an appointment.

Billing
Please bring your insurance card(s) to each visit. All co-pays and deductibles are the patient’s responsibility and expected to be paid on the day of service prior to being evaluated by the provider.
- If a patient has a no-copay/high-deductible plan, then the patient is expected to pay $65 that will go towards their office visit at the time of service or, if known by the provider, the full contracted insurance rate for the office visit at the time of service.
- If the patient needs the provider to complete paperwork (e.g. FMLA paperwork) outside of an office visit, then a $35 fee is required for completion.
Scheduling Appointments
Patients are seen by appointment only, except in the case of an emergency, which may cause delays. We ask for your understanding, knowing that if you ever require urgent care, we will give you prompt attention. To schedule appointments, please call (330) 422-4377. In the event that you are unable to keep your appointment time, please call at least 24 hours in advance to reschedule. There will be a $50 charge for no show appointments. If you miss 2 or more appointments due to a “no show” appointment, your chart will be reviewed and you may be discharged from this practice.

Hospital/Emergencies
If you have a life threatening illness, call 911 or go to the nearest Emergency Room and have a family member call our office.

After Hours/On Call Policy
Our office hours are Monday through Friday 9am-5pm. For urgent request, please contact our main office number rather than Spruce. If it is an urgent request and we are unable to address your concern, please go to the emergency department as soon as possible. For non-urgent request, you can leave a message for staff to be returned within the next 3-5 business days.

UH Twinsburg Urgent Care - 8819 Commons Blvd., Suite 101, Twinsburg, Ohio 44087 P: 234-837-5418

Cleveland Clinic Emergency Department - 8701 Darrow Rd, Twinsburg OH 44087 P:330-888-4176

By signing on the next page, I agree to the above policies

Please read and sign at the bottom to agree to the following statements:

I hereby authorize the release of medical information to insurance carriers, referring providers, and healthcare systems concerning my illness and treatment, when necessary. I hereby assign to the doctor all payments for medical services rendered to me or my dependent. I understand I am responsible for any amount not covered by insurance.

Acknowledgement of Treatment
I request and authorize Dr. Aarondeep Deol, Dr. Nazmine Deol, staff, and resident physicians, to perform general treatments and procedures as may be deemed necessary in my care.

Notice of Privacy Practices Acknowledgement
I, the undersigned, acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read, or have been offered a copy, and understand the notice (available upon request).

Medicare One Time Direction of Payments
If applicable, I give my permission to ask for Medicare payments for my medical care. I understand that Medicare needs information about me and my medical condition to make a decision about these payments. I give permission for that information to go to Medicare and the companies that handle Medicare payment requests. I understand that the Health Care Financing Administration (HCFA) is the government Medicare agency.

By Signing here, I state that the above information has been answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health.
Signature of Patient or Personal Representative*
Date*

MonthDayYear
Date
Personal Representative’s relationship to the patient:
Should be Empty:

New Patient Information Form

Medical Questions

Office Policies