Patient Forms - SPG | Scottsdale Physician Group

Patient Formsspg_dev2019-07-19T15:33:54+00:00

New Patient Information
Schedueld meds
In case of the requirements for scheduled meds (Narcotics and axiolitic), There must be an actual EMT visite.
Name*
First Last
Date Of Birth
Date of Birth*
DD
MM
YYYY
Gender
Gender*
- Male
- Female
Medicare#:*
RESIDANCE
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
(If Applicable)
Group Home / Assisted living Community Name:
Primary Contact:
Phone
Fax:
ADVANCE DIRECTIVES
We wish to follow your health directives. In order to do so, please provide copies of any legal documentation that will indetifty and provide guidance on your behalf.*
- Power of Attorney (Durable Medical, Financial, Mental Health)
- Living Will
- Guardianship
We wish to follow your health directives. In order to do so, please provide copies of any legal documentation that will identify and provide guidance on your behalf.
File
Power of Attorney/Guardian Name:
Address:
Phone
How were you referred to SPG Mobile?
Patient Name:*
First Last
EMERGENCY CONTACTS
Contact #1:
Phone
Relationship to patients:
- Full access of patient medical file
- Limit access of patient medical file
- No acces of patient medical file
Contact #2:
Phone
Relationship to patients:
- Full access of patient medical file
- Limit access of patient medical file
- No acces of patient medical file
INSURANCE INFORMATION
PLEASE NOTE FOR "HMO" INSURANCE PLANS.
We MUST be made the primary care physicians (PCP) on file with that insurance company.
We will be unable to see patients who do not make that assigmante
In order to make this change, simply call insurance company with the number found on the back of your insurance card and let them know that you will be changing your PCP.
Primary Insurance:
ID#:
Group #:
Address of Insurance
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address of Insurance
Secondary Insurance:
ID#:
Group #:
Address of Insurance
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address of Insurance
PLEASE ATTACH IMAGE OF INSURANCE CARDS. FRONT AND BACK
File
Patient Name
First Last
Preffered Pharmacy
Phone
Fax
MEDICATION

MEDICATION

MEDICATION NAME	DATE PRESCRIBED	STRENGHT	DOSE	PRESCRIBER

DRUG ALLERGIES

List

MEDICATION	REACTION

MEDICAL HISTORY
Which medical conditions do you have now or have had in the past?(Please check all that apply.)
Eyes and Ear
- Glasses / Contact lens
- Macular Degeneration
- Cataracts
- Hearing Loss
- Hearing Aid
- Chronic Ear Infection
- Ringing in ears
- Other
Gastrointestinal Tract
- Nausea
- Hearthburn / Reflux / GERD
- Ulcers
- Irritable Bowel
- Liver disease / Cirrhosis
- Hepatitis
- Gallbladder Disease
- Colon Polyps
- Diverticulosis
- Bleeding Problems
- Constipation
- Hemorrhoids
- Other
Kidney and Urinary Tract
- Frequent Bladder Infections
- Kidney Disease
- Third Choice
- Enlarged Prostate
- Urinary Incotinence
- Frequent Urination
- Kidney Stones
- Other
Heart
- Heart attack
- Heart failure
- High Blood Pressure
- Aortic Stenosis
- Hearth Valve Problems
- Angina
- High Colesterol
- Pacemaker
- Atrial fibrilation
- Irregular Hearthbeat
- Other
Lungs
- Asthma
- COPD / Emphysema
- Bronhitis
- Recurrent Pneumonias
- Other
Nervous System
- Dementia
- Stroke
- Epilepsy or Seizures
- Neuropathy / Nerve Demage
Glands
- Thyroid Overactive
- Tyroid Underactive
- Diabetes
- Other
Cancer: Location
MEDICAL HISTORY CONTINUED
Patient Name
Bones and Joints
- Gout
- Lower back pain
- Osteoporosis
- Arthritis
- Fractured Bones
Surgical History
Heart Bypass - Date
Heart Stent - Date
Heart Valve - Date
Pacemaker - Date
Defibrillator/ICD - Date
Hysterectomy - Date
Other past Surgeries and dates:
Other Health Concerns:
Have you recently been in the hospitalor skilled nursing facility in the past 3 months?
Name of facility:
Discharge Date:
Name of person completing new patient intake packet:
Relationship to patient:
Date:

New Patient Information

Date Of Birth

Gender

RESIDANCE

ADVANCE DIRECTIVES

EMERGENCY CONTACTS

INSURANCE INFORMATION

PLEASE ATTACH IMAGE OF INSURANCE CARDS. FRONT AND BACK

MEDICAL HISTORY

MEDICAL HISTORY CONTINUED

Surgical History

Have you recently been in the hospitalor skilled nursing facility in the past 3 months?