DEAR PATIENT: ENCLOSED IN THIS PACKET ARE YOUR NEW PATIENT INFORMATION FORMS. PLEASE FILL THEM OUT COMPLETELY, ACCURATELY, AND PLEASE PRINT . YOU WILL NEED TO BRING YOUR MEDICINE BOTTLES, IF YOU TAKE ANY MEDICATION, AND KNOW YOUR DRUG ALLERGIES. ALL PATIENTS UNDER THE AGE OF 18 ARE REQUIRED TO HAVE A PARENT OR LEGAL GUARDIAN PRESENT AT APPOINTMENT. NO SHOWS: THERE WILL BE A $75.00 FEE FOR NO SHOW APPOINTMENTS.  THIS FEE WILL BE CHARGED TO YOU, NOT YOUR INSURANCE. IF YOU NEED TO CANCEL OR RESCHEDULE YOUR APPOINTMENT PLEASE GIVE ADVANCED NOTICE, AS WE HAVE A LONG WAITING LIST OF PATIENTS WANTING TO SEE DR. BROWN. WHAT TO BRING: AT THE TIME OF YOUR APPOINTMENT YOU WILL NEED TO HAVE THE FOLLOWING WITH YOU: 1)THE NEW PATIENT PACKET FILLED OUT COMPLETELY. 2)MEDICINE BOTTLES (IF YOU ARE ON MEDICATION) 3)INSURANCE CARD 4)PHOTO ID CARD 5)REFERRAL (IF YOUR INSURANCE REQUIRES ONE) 6)ANY TESTING (FILMS, LABS/TEST RESULTS) THAT PERTAIN IF YOU HAVE HAD A CAT SCAN OR MRI PLEASE BRING IN THE ACTUAL FILMS, NOT A CD.THE CD WILL NOT OPEN ON OUR COMPUTERS. YOUR COOPERATION WILL AID IN THE ACCURATE TREATMENT AND HOPEFULLY, ALLEVIATE UNNECESSARY WAIT TIME. THANK YOU, BEACON HEAD AND NECK CLINIC For your convenience, please make a note of your appointment information: APPT DATE:________________     APPT TIME:______________ Patients Name: ______________________________________________________ Date: _________________ ================================================================================== MAIN COMPLAINT:____________________________________________________________________ How Long?__________________________________________________________________ Was this due to an injury? ________________________________________________ Have you had any X-Rays? __________________________________________________ Have you had any other testing? (lab work, etc.) __________________________ PLEASE BRING OR LET US KNOW OF PERTINENT X-RAY FILMS, LAB RESULTS, OR SPECIAL TEST RESULTS REFFERAL INFORMATION: Who suggested that you see us? ____________________________________________ Who is your Primary Care Physician? _______________________________________ Instructions: Please answer ALL questions to the best of your ability. If you are unsure about an answer, leave it blank. MEDICAL HISTORY: Personal History - Circle Yes or No, if yes, when? Asthma yes no ________ Tuberculosis yes no ________ Cancer yes no ________ Diabetes/Sugar yes no ________ Bleeding Disorders yes no ________ Heart Disease yes no ________ Kidney Disease yes no ________ Liver Disease yes no ________ High Blood Pressure yes no ________ Glandular Disorders yes no ________ Skin Disorders yes no ________ Neurologic Disorders yes no ________ Emotional Disorders yes no ________ Ulcer yes no ________ Other yes no ________ Family History - If yes, mother or father? Asthma yes no ________ Tuberculosis yes no ________ Cancer yes no ________ Diabetes/Sugar yes no ________ Goiter yes no ________ Heart Disease yes no ________ Stroke yes no ________ Free Bleeder yes no ________ Deafness yes no ________ (Note - We will discuss medications and allergies during your visit!) Please list all Operations: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Have you ever had a blood transfusion? _________ If yes, when? _________________________________ Do you drink alcohol? ____________ If yes, how much and how often? ___________________________________ Do you use tobacco? ____________ If yes, type and how often you use it? ____________________________ How long have you used tobacco? ___________________________________ Have you used tobacco in the past? ________________ Year you quit? ___________________________ Do you drink/use caffeine? (coffee, sodas, teas, drugs with caffeine) ____________ How much? ___________________________________________ List any additional information you wish to include in your medical record: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ REVIEW OF SYMPTOMS - Answer the following by checking the symptoms which apply to you. EARS: NOSE: ___ Pain ___ Blockage ___ Drainage or Discharge ___ Stuffiness ___ Itching ___ Frequent Colds ___ Fullness or Blockage ___ Itching ___ Difficulty hearing ___ Bad Odor ___ Dizziness ___ Pain or Tightness ___ Ringing or Noise ___ Nose Bleeds ___ Hay Fever ___ Frequent Snoring ___ Dryness MOUTH AND THROAT: ___ Drainage down back of throat ___ Frequent sore throats ___ Dryness of the throat ___ Itching or tickling ___ Difficulty swallowing ___ Dental Problems ___ Lump, Pressure, Tightness ___ Burning Tongue ___ Bleeding Gums ___ Hoarseness ___ Frequent Throat Clearing EYES: ___ Itching or Burning ___ Dryness ___ Swelling ___ Pain ___ Blurred Vision GENERAL: ___ Frequent Headaches ___ Menstrual Irregularities ___ Nervousness ___ Fatigue easily ___ Insomnia ___ Hot Flashes ___ Palpitations ___ Chest Pains ___ Cough Ted W. Brown, JR., M.D., FACS Beacon Head And Neck Clinic, P.A. Spring Hill Medical Mall, Suite 100 120 Medical Blvd. Spring Hill FL 34609 Office: 352-688-9282 ****************************************************************************** NOTICE OF PRIVACY PRACTICE: Your medical information may need to be sent to an outside source, such as another physician, hospitals, out-patient centers, or radiology centers for testing or surgery. Or, your medical information may need to be sent to your insurance carrier for processing of claims. We will not release your records for any other uses unless we have written authorization from you. I have been presented with a copy of the Notice of Privacy Practice, detailing how my health information may be used and disclosed as permitted under Federal and State Law, and outlining my rights regarding my health information. I have read the above statement and agree with the Privacy procedure. Patient Name: __________________________________________________________ Signature: _____________________________________________ Date: ________________ Relationship if not signed by Patient: _________________________________________ Optional: I authorize Beacon Head and Neck Clinic to disclose medical information to, or leave messages with the following: Name: __________________________________ Phone: _____________________________ Name: __________________________________ Phone: ______________________________