Adult Patient Registration Form

8/27/13
ADULT PATIENT REGISTRATION FORM

* Patient's Name * M * Address F * Birthdate
* City
* State
* Zip
* Home Phone
* Cell Phone
* Work Phone
* Social Security Number
* Email
* Marital Status
* Employment Status
* Student Status
* Employer
* Employer Address
* Referral Source
* Ethnicity Non Hispanic Hispanic Not Specified * Race
* Preferred Language
* Smoking Status
* Medications (include herbs, supplements and remedies)
0/420 characters
* Drug Allergies (please list drugs and describe the allergic reaction)
0/420 characters
https://fs10.formsite.com/drdom/form7/secure_index.html
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* Food/Environmental Allergies (Please list item and describe the reaction)
0/560 characters
DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING? General weight changes weakness fatigue unknown fever other
Psychological nervousness tension mood changes depression memory problems other
Head headache injury scalp problems hair problem other
Eyes glasses/contacts pain redness double vision cataracts other
Ears loss hearing ringing vertigo earaches discharge infections other
Nose hay fever nosebleeds frequent colds stuffiness polyps sinus problems others
Face pain numbness TMJ other
Mouth bleeding gums tongue pain tooth pain cold sores speech problems other
Throat frequent sore throats hoarseness difficulty swallowing other
Neck swollen glands neck pain neck stiffness thyroid problems other
Gastrointestinal poor appetite indigestion bloating frequent belching excess gas nausea
heartburn
vomiting
vomiting blood
pain
excessive thirst
gallstones
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jaundice

food intolerance food allergies other
constipation Cardiovascular chest pain Rectum hemorrhoids
diarrhea
high blood pressure
irregular ankle murmurs palpitations swelling pulse
shortness of breath
other
bloody stools
mucous stools
rectal bleeding
rectal fissure
other
Urinary blood in urine frequent urination painful urination infections kidney stones other
Men difficult erections lump on testicles discharge from penis sore on penis warts on penis
herpes
enlarged prostate
frequent urination
dribbling
getting up to urinate
other
Women abnormal PAP irregular periods breast lump menstrual pain PMS hot flashes
nipple discharge
sex
painful
vaginal discharge
vaginal warts
herpes
other
number of pregnancies Neurological fainting dizziness seizures
number of births
paralysis
tingling
tremors
other
Respiratory difficulty breathing chronic cough asthma emphysema chronic bronchitis TB other
Back pain spasms stiffness weakness other
Extremities weakness unsteadiness joint pain joint redness joint swelling
muscle pain
cramps
varicose veins
pain walking
swelling
other
Sleep difficulty falling asleep frequent waking early waking late waking snoring sleep walking other
Skin
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rashes skin color changes mole changes

lumps growths hair changes nail changes
easy bruising
hives
poor healing
easy bleeding
warts
allergies
other
Please list symptoms you currently have that were not mentioned above
0/420 words
CHECK CONDITIONS THAT YOU HAVE OR HAVE HAD IN THE PAST AIDS/HIV alcoholism cancer allergies appendicitis diabetes arthritis asthma epilepsy bleeding disorder glaucoma breast lump heart disease
chemical dependency chicken pox herpes
emphysema liver disease
hepatitis mumps skin problem
high kidney cholesterol disease pneumonia polio
measles
migraines
multiple sclerosis scarlet fever
pacemaker stroke
prostate rheumatic enlargement psychiatric fever disorder ulcers venereal disease vertigo/dizziness
TB/lung disorder
thyroid disease
other
VACCINES (check those you have received and include date if known) DPT Date Pneumonia Date
Hepatitis A
Date
Polio
Date
Hepatitis B
Date
Smallpox
Date
HIB
Date
Tetanus
Date
Influenza
Date
Typhoid
Date
MMR
Date
Varicella
Date
Other
* Hospitalizations (please list reason and date)
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0/420 characters
* Trauma History (list any mental, emotional or physical traumas with dates)
0/560 characters
* Never Well Since (list illnesses or treatments after which your level of health was never the same)
0/700 characters
HEALTH HABITS * Do You Smoke? Cigarettes Pipe Cigars N/A * How many ounces per day? N/A * How many cups per day * Amount per day/number of years
* Do you drink alcohol? beer wine mixed drinks
* Do you drink caffeinated beverages? coffee tea other N/A
* Do you use reacreational drugs? yes no
* Describe
* Are/were you exposed to any hazardous material at work? yes no * hours per week
* Describe
* Exercise or stress reduction activities? yes no
* Describe activity
* Please list physical and mental conditions that any of your relatives have had. Please state relationship. If deceased, please state age at time of death.
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0/900 characters
OFFICE POLICIES
New Patient Visits: First visits can take up to 1 hours. Depending on the patients needs, the emphasis will either be on homeopathy or osteopathy together with appropriate life-style recommendations. Please read the How To Report Symptoms page or the printed information which was sent to you by mail. Bring copies of recent laboratory work and other relevant medical reports as well as a list of all medications and supplements. If you are not using the online patient registration feature, please allow some extra time before your first visit to complete a patient registration form. The fees for a new patient visit are in the $425-$525 range. Initial visits for infants and children generally take less time and the fee is adjusted accordingly. Three business days notice is required to cancel a new patient visit. Fees for return visits vary based on the number and kind of procedures performed, generally in the $185- $265 range. Please call the office for details. Dr. Masiellos practice is office-based only, so patients are urged to maintain contact with conventional physicians for emergencies requiring hospitalizations, specialty consultation, surgery, diagnostic testing, gynecological services and routine cancer screening. He practices an integration of classical homeopathy and traditional osteopathy. Although homeopathy has been around for over 200 years, it is now considered to be alternative or non-conventional. Voice mail messages can be left 24 hours a day and he is available to established patients with urgent medical problems by cell phone. Health Insurance: We do not accept insurance payments nor do we participate in any networks or plans such as HMOs, PPOs, Workmans Compensation, No-Fault, Disability Plans or Medicaid. The practice is currently closed to new Medicare patients and patients on disability. Billing: Your treatment usually includes a medical office visit and an osteopathic treatment. As a courtesy, your claim will be submitted electronically on your behalf. If you do not have insurance, you will be given a receipt for tax purposes without insurance codes. Payment: Charges for all components of your treatment are due at the time of your visit. Cash, personal checks and credit cards (Master Card, Visa) are accepted. Patients are responsible for charges even if their deductible has not been met. There is no charge for a single dose of a remedy (pellets) dispensed at the time of the office visit. There is a fee for tinctures, liquid remedies and remedy tablets. A separate receipt will be issued for medication charges. Discount: There is a 15% discount for patients without health insurance or who are part of a network and will not get reimbursed for seeing a non-network physician. Discounted patients will receive a receipt without insurance codes for tax purposes. Receipts: Receipts for tax purposes are provided for patients without insurance. As a courtesy, all claims for patients with insurance will be submitted electronically. Cancelled or Missed Appointments: There is a fee for a missed office visit or for visits cancelled within less than 24 hours. Monday appointments must be cancelled on the previous Friday to avoid a cancellation fee. Lateness: The methods Dr. Masiello uses are labor-intensive and require the allotted time to complete so please maximize your experience by being on time. If you are late for your appointment and if the next patient has arrived early, the next patient may be seen during your appointment time in an effort to preserve the rest of the days schedule and not shortchange any one patient. Phone Consultations: Phone consultations are only for established patients who need homeopathic prescribing on weekends or after office hours. Phone consultations are not meant to replace an office visit. There is a $75 fee for phone consultations. Payment by credit card is required for the consultation. If the remedy prescribed during the phone consultation has not worked, you will be asked to come to the office for treatment the next day the office is open. The $75.00 fee will be deducted from the office visit fee so you will not pay twice for the same episode. Remedy kits for home prescribing are available via a link from this website. A Word About Fees: Dr. Masiello is dedicated to making holistic medicine available at a reasonable cost. He has set his prices at or below the fees listed in the Fair Health database. Return visits are based on the patients individual response to treatment and not on a fixed schedule. Homeopathy and osteopathy are used together to make the process time efficient and cost effective. The interval between visits increases as the patient responds to homeopathic remedies in the high potency range.
I understand that I am financially responsible for all charges, including any balance remaining after payment of health insurance benefits. I give my permission to release information needed for processing any health insurance claims.
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* I have read and agree to the above office policies Agree * Indicates Response Required
Submit
Holistic Family Medicine, LLC 141 East 55th Street New York, NY 10022 212-688-4818
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Adult Patient Registration Form

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Verfügbare Formate

Adult Patient Registration Form

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Verfügbare Formate

8/27/13

ADULT PATIENT REGISTRATION FORM

ADULT PATIENT REGISTRATION FORM

* Social Security Number

* Ethnicity Non Hispanic Hispanic Not Specified * Race

* Medications (include herbs, supplements and remedies)

ADULT PATIENT REGISTRATION FORM

* Food/Environmental Allergies (Please list item and describe the reaction)

Psychological nervousness tension mood changes depression memory problems other

Head headache injury scalp problems hair problem other

Eyes glasses/contacts pain redness double vision cataracts other

Ears loss hearing ringing vertigo earaches discharge infections other

Face pain numbness TMJ other

Throat frequent sore throats hoarseness difficulty swallowing other

ADULT PATIENT REGISTRATION FORM

constipation Cardiovascular chest pain Rectum hemorrhoids

high blood pressure

irregular ankle murmurs palpitations swelling pulse

number of pregnancies Neurological fainting dizziness seizures

Back pain spasms stiffness weakness other

Extremities weakness unsteadiness joint pain joint redness joint swelling

ADULT PATIENT REGISTRATION FORM

chemical dependency chicken pox herpes

emphysema liver disease

hepatitis mumps skin problem

high kidney cholesterol disease pneumonia polio

multiple sclerosis scarlet fever

* Hospitalizations (please list reason and date)

ADULT PATIENT REGISTRATION FORM

* Do you drink alcohol? beer wine mixed drinks

* Do you drink caffeinated beverages? coffee tea other N/A

* Do you use reacreational drugs? yes no

* Exercise or stress reduction activities? yes no

ADULT PATIENT REGISTRATION FORM

ADULT PATIENT REGISTRATION FORM

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