emergency screening

EMERGENCY SCREENING
Welcome to MedStar PromptCare. In order to provide the very best care for you and also protect your privacy, we ask
that you complete this form immediately upon presentation to the practice and provide it to the Patient Services
Coordinator at the front reception desk. Your health is of the utmost importance to us and we are committed to
serving you.
PLEASE PROVIDE US THE REASON FOR YOUR VISIT TODAY
Date of Birth:
Is today’s visit related to work place injury?  Yes  No
Is today’s visit related to an auto accident?  Yes  No
ARE YOU (OR THE PATIENT) EXPERIENCING ANY OF THE FOLLOWING AT THIS TIME?
1. Chest pain (not associated with coughing or flu symptoms), pressure or heaviness in the chest,
chest pain that radiates into the shoulder, arm, back or jaw, heart attack
2. Difficulty breathing, shortness of breath, asthma attack
3. Severe or uncontrolled bleeding
4. Loss of consciousness, fainting or seizure
5. Foreign object in the eye or chemicals splashed in the eye
6. Medication overdose or ingestion of a chemical
7. Sudden onset of one-sided extremity or facial weakness, difficulty speaking, blurred vision,
dizziness, headache, confusion, disorientation or other symptoms of a stroke
8. Possible contagious rash (such as chickenpox, scabies, measles)
9. Fall or motor vehicle crash with neck pain, numbness, weakness or tingling in the extremities
10. Severe abdominal pain
CHECK ONE:  NO
Signature
 YES (if yes, please circle the symptom-event above)
Patient Name
Name of Patient Representative Signing for Patient
(required if the patient is a minor or an adult who is unable to sign this form)
Date
Relationship of Patient Representative to Patient
AUTOMOBILE OR WORK INJURY
Please complete this form if the reason for today’s care is an automobile accident or an injury at work
and this is the first time you are being seen by MedStar PromptCare for this particular injury.
PATIENT - ACCIDENT INFORMATION
Patient Name:
Today’s Date:
Social Security Number:
Date of Accident:
State Where Accident Occurred:
INSURANCE INFORMATION
Insurance Company Name:
Claim Number:
Phone Number:
Billing Address:
I hereby authorize MedStar PromptCare to furnish the insurance carriers listed above my medical
information. I hereby assign MedStar PromptCare all payments for medical services rendered to myself
or my dependents until revoked in writing. I understand that I am responsible for any amount not
covered by insurance at the time of service. I also understand that I am responsible for collection and
legal costs should my account be turned over to a collection agency.
Signature:
Date:
PATIENT REGISTRATION, PAGE 1
Please complete Patient Registration, Page 1 and Page 2, if the patient is new to MedStar Health, has not received care
from MedStar in the past three years, or if the patient has had a significant change in information (demographic,
insurance, medical history).
PATIENT INFORMATION
Patient’s Name (Last)
Gender
(First)
Date of Birth
Age
Address
Marital Status
(MI)
Race
Language
City
Social Security #
Employed (Y/N)
State
Evening Phone
Daytime Phone
Employer/School
Relationship to Guarantor
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name
Address
Zip
Relationship to Patient
City
State
Zip
PRIMARY INSURANCE
Name of Insurance
Address
Group Number
Insured’s Date of Birth
Insured’s ID #
Insured’s Social Security #
Copay
Insured’s Party Name
SECONDARY INSURANCE
Name of Insurance
Address
Group Number
Insured’s Date of Birth
Insured’s ID #
Insured’s Social Security #
Copay
Insured’s Party Name
Effective Date
Effective Date
PRIMARY CARE PHYSICIAN
Primary Care Physician Name
Practice Phone
Practice Name and Address
Completed by:  Patient  Parent/Guardian/Other
Phone #
Signature:
PATIENT REGISTRATION, PAGE 2
Gender:  Female  Male Date of Birth:
Patient’s Full Name:
PHARMACY: Would you like your prescriptions electronically transferred to a pharmacy?  Yes  No
Pharmacy Name:
Phone No.:
Fax No:
Pharmacy Address:
MEDICAL, FAMILY, SOCIAL HISTORY
Medication-Drug Allergies:
Current Medications:
Have you been diagnosed with any of the following:
 Abnormal Heart Rhythm
 Anxiety
 Arteriosclerosis
 Arthritis
 Asthma
 Blood Clots
 Cancer
 Cholesterol - Triglyceride Disorder
 COPD - Pulmonary Disease
 Congestive Heart Failure (CHF)
 Depression
 Diabetes
 Gallbladder Disease
 Glaucoma
 Headaches
 Hiatal Hernia
 Hypertension - High Blood Pressure
 Kidney Disease - Uremia
 Kidney Stones
 Hypotension - Low Blood Pressure
 Lung Disease
 Muscle Disease
 Pulmonary Hypertension
 Renal Disease
 Seizure Disorder
 Sleep Disorders
 Stomach - GI Disorders
 Stroke
 Thyroid Disorders
 Tremor
 Ulcer Disease
 Urinary Infections
Surgeries – Procedures
 Appendix Removal
 Blood Transfusions
 CABG (Heart Surgery)
 Gallbladder Removal
 Hernia Repair
 Hysterectomy (circle: Total-Partial)
 Pacemaker
 Tonsils Removal
 Tubal Ligation
 TURP
 Stomach Surgery
 Thyroid Surgery
 Spleen Surgery
Children, Ages 10 and under
 Premature - Complications at Birth
 Ear Infections
 Febrile Seizure
Other Medical History:
Vision and Hearing  Hearing Problems  Wear Hearing Aid  Wear Contact – Glasses  Wear Glasses for Reading Only
Birth Control  Yes  No Type:
Last Menstrual Period:
Biological Mother:  Alive  Deceased at age
from:
Biological Father:  Alive  Deceased at age
from:
Tobacco:  No  Yes
Alcohol:  Never  Rarely  Occasional  Heavy
Recently Traveled Abroad:  No  Yes, Location:
Dates:
Other Relevant Medical History:
Completed by:  Patient  Parent/Guardian/Other
Signature:
REVIEW OF SYSTEMS
Today’s Date:
Patient’s Full Name:
Completed by:  Patient  Parent/Guardian/Other:
Gender:  Female  Male Date of Birth:
As part of your current illness-injury, please indicate which of the following you are experiencing:
CONSTITUTIONAL
 Yes  No - Fever
 Yes  No - Chills/Sweats
 Yes  No - Fatigue
CHILDREN—BABIES
 Yes  No - Decreased Activity
 Yes  No - Inconsolable/Fussy
 Yes  No - Crying More
 Yes  No - Drinking/Eating Less
 Yes  No - Attends Daycare/School
 Yes  No - Pulling at Ears
 Yes  No - Diaper Rash
EYES
 Yes  No - Eye Pain
 Yes  No - Sensitivity to Light
 Yes  No - Redness
 Yes  No - Vision Changes
EARS—NOSE—THROAT—MOUTH
 Yes  No - Sore Throat
 Yes  No - Nasal Congestion
 Yes  No - Runny Nose
 Yes  No - Ear Pain/Ache
 Yes  No - Nasal Foreign Body
 Yes  No - Tooth Pain
Physician Signature:
RESPIRATORY
 Yes  No - Cough  w/Sputum  w/Blood
 Yes  No - Shortness of Breath
 Yes  No - Wheezing
 Yes  No - Pain with Coughing or Breathing
CARDIOVASCULAR
 Yes  No - Chest Pain
 Yes  No - Heart Racing/Palpitations
 Yes  No - Leg Swelling
 Yes  No - Difficulty Breathing
SKIN—HAIR—NAILS
 Yes  No - Rash
 Yes  No - Skin redness
 Yes  No - Insect Bite/Sting
 Yes  No - Itching
 Yes  No - Cuts, Bumps, Scrapes, Bruises
 Yes  No - Finger—Toe Nail Problem
GENITOURINARY
 Yes  No - Urination Pain/Discomfort/Pressure
 Yes  No - Blood in Urine
 Yes  No - Kidney Pain
 Yes  No – Vaginal or Penile Discharge
 Yes  No - Genital Pain or Lesions
 Yes  No - Pregnant
 Yes  No - Breast Feeding
 Yes  No - Using Birth Control Pills
GASTROINTESTINAL
 Yes  No - Abdominal Pain
 Yes  No - Indigestion/Reflux
 Yes  No - Nausea
 Yes  No - Vomiting
 Yes  No - Diarrhea
 Yes  No - Constipation
 Yes  No - Black or Bloody Stool
 Yes  No - Hemorrhoid
 Yes  No - Rectal Problem
MUSCULOSKELETAL
 Yes  No - Back Pain
 Yes  No - Neck Pain
 Yes  No - Muscle Aches
 Yes  No - Bone Pain
 Yes  No - Joint Pain
 Yes  No - Joint Swelling
 Yes  No - Extremity Swelling
NEUROLOGICAL
 Yes  No - Headache
 Yes  No - Dizziness
 Yes  No - Loss of Consciousness
 Yes  No - Numbness/Tingling
 Yes  No – Seizure
HEMATOLOGY—ENDOCRINE
 Yes  No - Easy Bruising
 Yes  No - Prolonged Bleeding
 Yes  No - Swollen Glands
 Yes  No - Excessive Thirst
 Yes  No - Excessive Hunger
Review Date and Time:
FORM: ROSGEN01072014
Privacy and Billing Procedures Authorization and Acknowledgement
These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates
of service. I understand I may revoke this authorization by informing MedStar in writing but if I do revoke this authorization, it will
not affect anything prior to the date the revocation is received by MedStar.
Acknowledgement of Receipt of Notice of Privacy Practices
Authorization to Release Information to Family/Friends or Others
I have received a copy of MedStar’s Notice of Privacy Practices. I authorize MedStar to release any information regarding my
treatment including lab results, x-rays and medical records, to the following individuals (MedStar may not release information or
records to the named individuals unless you identify them here):
Name:
Relationship to Patient:
Name:
Relationship to Patient:
Name:
Relationship to Patient:
MedStar will use my home phone number and/or mobile phone and my primary address supplied during registration to contact
me, including leaving messages, regarding my treatment including lab results, x-rays and medical records. I will ensure this
information is up-to-date at every visit.
Authorization to Treat and Bill
I consent to be treated by MedStar. If I am not the patient being treated today I am authorized to consent to treatment and billing
for the patient identified below. I authorize MedStar to bill my medical insurance for the care I receive today and to release any
information the insurance carrier requires to process this bill. I authorize payment of medical benefits to MedStar, or to outside labs
as described below, for all services performed and billed by MedStar. I understand that I am responsible for all charges for the
treatment I receive at MedStar today.
As a courtesy, MedStar will bill my medical insurance. If I do not provide complete and accurate insurance information to MedStar, I
understand MedStar may not receive payment from my carrier and I will be entirely responsible for my bill. Even after my medical
insurance company pays MedStar’s bill, I may owe MedStar payment for services not covered by my insurance and I agree to pay
these promptly to MedStar. I understand that MedStar may send lab specimens to an outside laboratory. I authorize any lab
performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all
services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I
understand that MedStar is not responsible for payment to outside labs for tests provided to me.
To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service
that MedStar may choose not to bill insurance and may decline credit/debit cards and checks as a form of payment. I understand
that if I fail to pay MedStar for services provided to me, the balance owed may be sent to collections and I may incur collection costs
of up to 25% in addition to the amount owed for treatment. I understand that I may contact MedStar to work out payment
arrangements that may prevent this additional cost.
Signature:
Date:
Patient Name:
Patient DOB:
Name of Patient Representative Signing for Patient
Relationship of Patient Representative to Patient
(required if the patient is a minor or an adult who is unable to sign this form)