Hospital Intake Sheet

Massachusetts General Hospital Plastic & Reconstructive Surgery New Patient Intake Form

Division of Plastic & Reconstructive Surgery    William G. Austen, Jr. MD    Eric C. Liao, MD, Ph.D.

Wang Ambulatory Care Center    Curtis L. Cetrulo, Jr. MD    Jonathan Winograd, MD

15 Parkman Street, Suite 435    Amy Colwell, MD    Michael Yaremchuk, MD

Boston, MA 02114    Jason S. Cooper, MD

Today’s Date: MGH Unit #

Patient Name:

Address:

City: State: Zip:

Home Phone: Work/Cell Phone:

Employer: Occupation:

Date of Birth: Age: Emergency Contact:

Social Security Number: Relationship to Patient:

Marital Status: M / S / D / W No. of Children Contact Telephone:

E-mail Address: How did you hear about us?

MGH website

Physician Referral

Friend or Relative

Internet Search

Magazine/Newspaper

Other

Primary Care Physician:

Address: Phone:

Referred by (Physician):

Address: Phone:

INSURANCE INFORMATION:

Primary Insurance: Policy Holder Name:

Policy Number: Group Number:

Secondary Insurance: Policy Holder Name:

Policy Number: Group Number:

Assignment and Release

I hereby authorize my insurance benefits to be paid directly to the Massachusetts General Physicians Office (MGPO) for services rendered. I hereby acknowledge that I am responsible for unpaid balances. I also authorize the above physician practice to release medical information necessary to process any claims submitted on my behalf.

Please note this important information about your insurance

We, the Massachusetts General Physicians Organization, participate with Medicare, Medicaid, Blue Cross/ Blue Shield and numerous Health Care Management organizations. If you are covered by a managed care plan, it is the responsibility of the patient to obtain prior authorization for all services rendered at this healthcare facility. A referral form, authorization number and /or name and number of your primary care physician (PCP) should be provided at the time of your visit. If you do not have the proper authorization or referral at the time of your visit, you agree to assume responsibility for all charges related to your visit. You are also required to pay all co-payments at the time of your visit.

Reason for Today’s visit:

Have you consulted other doctors regarding this problem? Y/N

If yes, please list:

Have you had any previous surgery for this problem?

PAST MEDICAL HISTORY:

General Health: Height: Weight:

Date of last Physical Examination:

Was an electrocardiogram performed? Y/N    Chest X-Ray Y/N    Are you pregnant? Y/N

Do you currently wear a Pacemaker or ICD? Y/N

If yes, who is your Cardiologist: Telephone:

OTHER CURRENT MEDICAL PROBLEMS (Please list)

What is your daily or previous consumption of: Coffee/Tea Tobacco Alcohol

Aspirin (Tylenol, Bufferin, Anacin, Contac, etc) Steroids (Cortisone)

CURRENT MEDICATIONS (Please list)

Include dosages (including birth control pills, diuretics, blood pressure or heart medication, tranquilizers, hormones, blood thinners, sleeping pills or pain medications, over the counter medications, vitamins and herbal supplements)

Do you have any Allergies to any medications? (Please list)

Do you have any other Allergies? (Please list)

Are you now or have you ever received psychiatric assistance? Y/N

Name and address of Psychiatrist or Psychologist:

PREVIOUS SURGERY (Please list with dates)

Have you had complications from previous surgery? Y/N

If yes, please describe the complication:

Has anyone in your family had complications from anesthesia? Y/N

Do you bruise easily? Y/N

PREVIOUS ILLNESSES (Place an X after any illness you have had)

Heart Murmur    Rheumatic Fever    Heart Attack

Heart Disease    High Blood Pressure    Blood Transfusion

Pneumonia    Pleurisy    Emphysema

Kidney Trouble    Bladder Trouble    Thyroid Trouble

Hiatal Hernia    Abnormal EKG    Asthma

Anemia    Bleeding Disorder    Jaundice

Hepatitis    Ulcer    Arthritis

Diabetes    Phlebitis    Epilepsy

Abnormal Chest X-Ray    AIDS    Venereal Disease

Tumor    Cancer    Stroke

Nervous Disorder    Glaucoma    Albuminuria

Nerve Deficit    Kidney Stones    Tuberculosis

Other

PRESENT SYMPTOMS (Place an X after any symptoms you have now)

Fever/ Chills    Excess Sweating    Fatigue

Vision Problem    Eye Pain/Redness    Hearing Trouble

Nose Bleeds    Throat Discomfort    Cough

Sputum    Bloody Sputum    Wheezing

Chest Pains    Heat Intolerance    Heart Skipping

Shortness of Breath    Swollen Feet or Ankles    High Blood Pressure

Jaundice    Heartburn    Difficulty Swallowing

Abdominal Pain    Nausea/Vomiting    Vomiting Blood

Black Stools    Rectal Bleeding    Diarrhea

Acid Indigestion    Backache    Arthritis

Night Time Urine    Bruise Easily    Bleed Easily

Increased Thirst    Increased Urine    Fainting

Numbness    Tremor    Muscle

Weakness    Nervousness    Depression

Other