Book an appointment. By PhonePhone (786) 520-2688 FAX: (954) 699-0670By Emailjrw@nephronpartners.com Name * First Name Last Name Email * Message * Thank you! If you are a new patient, please fill out the registration forms listed below in advance. Registration Form. Today's Date MM DD YYYY PCP PATIENT INFORMATION Patient's last name First name Middle Name Is this your legal name? Yes No Mr. Mrs. Miss. Ms. Marital's Status Single Married Divorced Separated Widowed If not, what is your legal name? Former name: Birth date MM DD YYYY Age Sex M F Address Address 1 Address 2 City State/Province Zip/Postal Code Country P.O. Box Social's Security Number Phone (###) ### #### Occupation Employer Employer phone number (###) ### #### Choose clinic because / referred to clinic by Dr Insurance plan Hospital Family Friend Close to home/work Yellow pages Other INSURANCE INFORMATION Please give your insurance card to the receptionist. Person responsible for bill Birth date MM DD YYYY Address (if different) Address 1 Address 2 City State/Province Zip/Postal Code Country Number Is this person patient here? Yes No Occupation Employer Employer address Employer phone number (###) ### #### Is this person covered by insurance? Yes No Please indicate primary insurance Subscriber's name First Name Last Name Subscriber's S.S. number Birth date MM DD YYYY Group Number Policy number Co-payment $ Patient's relationship to subscriber Self Spouse Child Other Name of secondary insurance (if applicable) Subscriber's name First Name Last Name Group number Policy number Patient's relationship to subscriber Self Spouse Child Other IN CASE OF EMERGENCY Name of local friend (not living at same address) First Name Last Name Relationship to patient Phone number (###) ### #### Work phone number (###) ### #### The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that i am financially responsible for any balance. I also authorize ( name of Practice) or insurance company to release any information required to process my claims. Patient/Guardian signature (printed name) Date MM DD YYYY HIPAA PRIVACY AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. seq., and regulations promulgated thereunder, as amended from time to time (collectively referred to as "HIPAA"). This authorization affects your rights in the pnvacy of your personal healthcare information. Please read it carefully before signing. James W Loewenherz, MD PA; Jose R Weisinger, MD PA; ("Covered Entity") will not condition treatment payment, enrollment in a health plan, or eligibility for benefits, as applicable, on your providing authorization for the requested use or disclosure. YOU MAY REFUSE TO SIGN THIS AUTHORIZATION. By signing this authorization you acknowledge and agree that Covered Entity may use or disclose Any and All Medical information related to the care provided for the purpose(s) of Providing medical care, Communicating with other care providers, Communicating with Hospitals, laboratories, clinics and other entities involved in your care and [describe intended use]. By signing this authorization you agree that Covered Entity or its Business Associates may disclose your personal health care information to: Care Providers, Affiliated Hospitals, Clinics and Consultants, Record custodians, and other related entities. [identify intended recipients]. Further, by signing this authorization you acknowledge that you have been provided a copy of and have read and understand Covered Entity's HIPAA Privacy Notice containing a complete description of your rights, and the permitted uses and disclosures, under HIPAA. While Covered Entity has reserved the right to change the terms of its Privacy Notice, copies of the Privacy Notice as amended are available from Covered Entity at any of its offices or by sending a written request with return address to: 8525 SW 92nd St, Ste D-15, Miami, FL 33156. . In accordance with your rights under, and subject to certain restrictions imposed by, HIPAA, you may inspect or copy your PHI in the designated record set maintained by Covered Entity for as long as the PHI is maintained in the designated record set. You have the right to revoke this authorization, in writing, at any time, except to the extent that Covered Entity has taken action in reliance on it. A revocation is effective upon receipt by Covered Entity of a written request to revoke and a copy of the executed authorization form to be revoked at the address listed above. This authorization shall expire upon the earlier occurrence of: (a) revocation of the authorization, (b) a finding by the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights that this authorization is not in compliance with requirements of HIPPA, (c) complete satisfaction of the purposes for which this authorization was originally obtained, to be determined in the reasonable discretion of Covered Entity, or (d) liz years from the date this authorization was executed. By signing this authorization you acknowledge and agree that any information used or disclosed pursuant to this authorization could be at risk for redisclosure by the recipient and no longer protected under HIPAA. Covered Entity will provide (name of patient) with a copy of this signed authorization, upon request. Acknowledged and agreed to by: PATIENT By Print Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date MM DD YYYY or, ON BEHALF OF PATIENT By Print Name As Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date MM DD YYYY HELTH HISTORY QUESTIONNAIRE All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name First Name Last Name Sex M F DOB Marital status Single Partnered Married Separated Divorced Widowed Previous or referring doctor Date of last physical exam MM DD YYYY PERSONAL HEALTH HISTORY Childhood illness Measles Mumps Rubella Chickenpox Rheumatic Fever Polio List any medical problems that other doctor have diagnosed Surgeries Year / Reason / Hospital Other hospitalizations Year / Reason / Hospital Have you ever had a blood transfusion? Yes No List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers Name the drug / Strength / Frequency taken Allergies to medications Name the drug / Reaction you had HEALTH HABITS AND PERSONAL SAFETY ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL. Exercise Sedentary (no exercise) Mild exercise (i.e., climb stairs, walk 3 books, golf) Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) Regular vigorous exercise (i.e., work or recreation 4x/week for 30 min.) Diet Are you dieting? Yes No If yes, are you on a physician prescribed medical diet? Yes No Number of meals you eat in an average day? Rank salt intake? Hi Med Low Rank fat intake Hi Med Low Caffeine None Coffee Tea Cola Number of cups/can per day? Alcohol Do you drink alcohol? Yes No If yes, what kind? How many drinks per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Yes No Have you ever experienced blackouts? Yes No Are you prone to "binge" drinking? Yes No Do you drive after drinking? Yes No Tobacco Do you use tobacco? Yes No Cigarettes pks./day Chew #/day Pipe #/day Cigars #/day # of years Or year quit Drugs Do you currently use recreational or street drugs? Yes No Have you ever given yourself street drugs with a needle? Yes No Sex Are you sexually active? Yes No If yes, are you trying for a pregnancy? Yes No If not trying for a pregnancy list contraceptive or barrier method used: Any discomfort with intercourse? Yes No Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of the illness? Yes No Personal safety Do you live alone? Yes No Do you have frequent falls? Yes No Do you have vision or hearing loss? Yes No Physical and/or mental abuse have also become a major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider? Yes No FAMILY HEALTH HISTORY Father's age Significant health problems Mother's age Significant health problems Sibling's age Sex M F Significant health problems Sibling's age Sex M F Significant health problems Sibling's age Sex M F Significant health problems Sibling's age Sex M F Significant health problems Sibling's age Sex M F Significant health problems Sibling's age Sex M F Significant health problems Children's age Sex M F Significant health problems Children's age Sex M F Significant health problems Children's age Sex M F Significant health problems Children's age Sex M F Significant health problems Grandmother's age (maternal) Significant health problems Grandfather's age (maternal) Significant health problems Grandmother's age (paternal) Significant health problems Grandfather's age (paternal) Significant health problems MENTAL HEALTH Is stress a major problem fro you? Yes No Do you feel depressed? Yes No Do you panic when stressed? Yes No Do you have problems with eating or your appetite? Yes No Do you cry frequently? Yes No Have you ever attempted suicide? Yes No Have you ever seriously thought about hurting yourself? Yes No Do you have trouble sleeping? Yes No Have you ever been to a counselor? Yes No WOMEN ONLY Age at onset of menstruation Date of last menstruation MM DD YYYY Every how many days you get your period? Heavy periods, irregularity, spotting, pain, or discharge? Yes No Number of pregnancies Number of live births Are you pregnant or breastfeeding? Yes No Have you had a D&C, hysterectomy, or Cesarean? Yes No Any urinary tract, bladder, or kidney infections within the last year? Yes No Any blood in your urine? Yes No Any problems with control of urination? Yes No Any hot flashes or sweating at night? Yes No Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Yes No Experienced any recent breast tenderness, lumps, or nipple discharge? Yes No Date of last pap and rectal exam? MM DD YYYY MEN ONLY Do you usually get up to urinate during the night? Yes No If yes, # of times Do you feel pain or burning with urination? Yes No Any blood in your urine? Yes No Do you feel burning discharge from penis? Yes No Has the force of your urination decreased? Yes No Have you had any kidney, bladder, or prostate infections within the last 12 months? Yes No Do you have any problems emptying your bladder completely? Yes No Any difficulty with erection or ejaculation? Yes No Any testicle pain or swelling? Yes No Date of last prostate and rectal exam? MM DD YYYY OTHER PROBLEMS Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. Skin Head/Neck Ears Nose Throat Lungs Chest/Heart Back Intestinal Bladder Bowel Circulation Briefly explain Recent changes in Weight Energy level Ability to sleep Other pain/ discomfort Thank you!
