New Patient Online Form

*Patient Name:
*Date of Birth:
*Social Security #:
Primary Care Physician:
*Referring Physicians:
Surgeon or other physicians you would like notified of your progress:
*Home Address:
*Home Phone #:
Work #:
Cell #:
E-Mail Address:

Check In Information

*Location:	Burleson Cleburne Denton Fort Worth - Central Campus Fort Worth - Southwest Granbury Mineral Wells Stephenville Weatherford Other
Physician:	Matthew L. Cavey, M.D. Gregory Friess, D.O. Shanthi Ganesa, M.D. Nathan Kim, M.D., Ph.D. Peter LaNasa, M.D. H. Lance Mandell, M.D. Shadan Mansoor, M.D. Ann-Margaret Ochs, D.O. Ray D. Page, D.O., PhD Vinaya Potluri, M.D. Bibas Reddy, D.O. Michael Ross, M.D. Mary Ann Skiba, D.O. DeEtte Vasques, D.O. Henry Q. Xiong, M.D., PhD Robyn R. Young, M.D.

Patient Information

Employer:
Work Phone:
Retired:	Yes No
If yes, where from?:

Spouse/Policyholder Information

Name of Spouse:
Date of Birth:
Social Security #:
Retired?:	Yes No
If yes, where from?:
Employer:
Work Phone #:

Primary Insurance Information

Policy Type:	Group Individual
*Insurance Name:
*ID #:
Group #:
*Insurance Telephone #:
Who's employer is insurance through?:	Patient Spouse

Secondary Insurance Information

Policy Type:	Group Individual
Insurance Name:
ID #:
Group #:
Insurance Telephone #:
Who's employer is insurance through?:	Patient Spouse

Emergency Contact

*Name:
* Relationship:
Address:
*Telephone:

To whom may we release information and records regarding your care

Name:
Relationship:
Name:
Relationship:

AS A COURTESY TO OUR PATIENTS, WE WILL FILE WITH YOUR INSURANCE. I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS THE CLAIM. I HEREBY AUTHORIZE PAYMENTS DIRECTLY TO UNDERSIGNED PHYSICIAN(S) FOR THE SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE O FOR HIS/HER SERVICE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES NOT COVERED BY THIS AUTHORIZATION.

*Date:
*Signature of Insured:

Do you presently have or ever had any of the following?

				Year Diagnosed
Diabetes:	Yes	No
High Blood Pressure:	Yes	No
Heart Disease:	Yes	No
High Cholesterol:	Yes	No
Chest Pain:	Yes	No
Emphysema:	Yes	No
Asthma:	Yes	No
Colon Polyps:	Yes	No
Rectal Bleeding:	Yes	No
Strokes / TIA’s:	Yes	No
Brain Injury:	Yes	No
Seizures:	Yes	No
Dizziness:	Yes	No
Glaucoma:	Yes	No
Thyroid Problems:	Yes	No
Hepatitis:	Yes	No
Ulcers:	Yes	No
Depression:	Yes	No
Cataracts:	Yes	No

Other:
Are You in Pain for any Reason?:
Pain Medicine:

Please Rate Your Pain on a Scale of 0-10 (0 = No Pain and 10 = Worse Pain):
Do You Have Any Difficulty Reading or Hearing Verbal Instructions in English?:

Surgical History

Please list any surgical procedures you have had performed and the year done.

Procedure		Year

Personal Medical History

Drug Allergies?:
Other Allergies?:
What is Your Height?:
Weight?:

Do You Exercise Routinely?:	Yes	No
Do You Smoke?:	Yes	No

How Much?:

Have You Quit Smoking?:

Yes

No

How Long Did You Smoke For?:
How Many Packs a Day?:

Do You Drink Alcohol?:

Yes

No

How Much?:
How Many Days a Week?:

Have You Worked With or Been Exposed to any Chemicals?:

What Hobbies or Pastimes Do You Have?:

Are You Currently Employed?:

Yes

No

If Yes, What Kind of Work Do You Do?:

Are You on Disability?:

Yes

No

Please list your current medications.

Drug/Herbal Name		Dosage