New Gen Medical P.C.

Date of Appointment:

860 58th St, Brooklyn, NY 11220 Tel: 718-435-8181

Patient Information
Patients First Name

Sex

Marital Status

Middle Name

Last Name

Date of Birth (Age)

Social Security Number

Patients Address

City

(as it appears on insurance card or ID)

State

Home Phone

Mobile Phone

Email Address

Referred by

Primary Care Physician

Primary Care Physician Phone

Pharmacy

Pharmacy Phone

Zip

Pharmacy Address

Patient Employer/School Information

Occupation

Employer/School

Employer/School Address

Employer/School Phone

City

State

Zip

Emergency Contact Information

Emergency Contact Phone

Emergency Contact Name

Relation to Patient

Billing and Insurance

Primary Health Insurance
Insurance Company

Plan Number

Plan

Group Number

Insureds Employer/School

Insureds Name (as it appears on insurance card or ID)

Relation to Patient

Insureds Phone Number

Insureds Address

City

State

Insureds Social Security Number

Zip

Insureds Birthdate

Secondary Health Insurance

Insurance Company

Plan Number

Plan

Group Number

Insureds Name (as it appears on insurance card or ID)

Insureds Employer/School

Insureds Social Security Number

Relation to Patient

Insureds Phone Number

Responsible Party
Billing Name (if other than patient)

Phone

Address

City

Signature of Patient or Authorized Guardian

Date

Check-In by

Relation to Patient

State

Zip

Date of Appointment:
Name

Gender

Age

Reason for Visit

Excellent

Current Medications

Good

Fair

Poor

Allergies

Name

Dosage

Frequency

Name

Dosage

Frequency

Name

Dosage

Frequency

Name

Dosage

Frequency

Adhesive Tape

Antibiotics

Latex

Barbiturates (Sleeping Pills)

Aspirin

Iodine

Codeine

Sulfa

Local Anesthetics

Name

Reaction

Name

Reaction

Past Medical History

Alcoholism

Back Problems

Ear Problems

Hepatitis - A, B, or C

Measles

Skin Disorder

Allergies

Bleeding Disorder

Eating Disorder

High Blood Pressure

Migraines

Stomach Ulcer

Anemia

Blood Disease

Epilepsy

High Cholesterol

Osteoporosis

Substance Abuse

Anxiety Disorder

Blood Transfusion

Glaucoma

Joint Disorder

Pneumonia

Thyroid Disorder

Arthritis

Cancer

Gout

Kidney Disorder

Polio

Tuberculosis

Asthma

Diabetes

Heart Disease

Liver Disorder

Rheumatic Fever

Venereal Disease

AIDS / HIV

Depression

Heart Problems

Lung Disease

Stroke

Hospitalizations & Surgeries

Women Only:

Reason

Date

# of Pregnancies

# of Miscarraiges

# of Abortions

Reason

Date

Last Pap Smear

Last Mammogram

Birth Control Method

Family History

Lifestyle Factors

Alcoholism

Cancer

Joint Disorder

Allergies

Depression

Kidney Disease

Alzheimers

Diabetes

Liver Disorder

Anemia

Epilepsy

Lung Disease

Anxiety

Genetic Disorder

Migraines

Arthritis

Glaucoma

Psychiatric Disorders

Asthma

Heart Disease

Osteoporosis

AIDS/HIV

Hepatitis

Stroke

Bleeding Disorder

High Cholesterol

Substance Abuse

Blood Disorder

High Blood Pressure

Thyroid Disorder

Details:

# of partners in past year

Yes

No

Yes

No

Yes

No

Yes

No

# of years

Yes

No

# packs/day

Yes

No

# drinks/week

# drinks/day
# times/week

Check-In by

# of Living

# packs/day

# times/week

Name

Gender

Date of Appointment:

Age

Review of Systems
General

Gastrointestinal

Musculoskeletal

ENT

Chills

Appetite Gain

Bleeding Gums

Back Pain

Dizziness

Appetite Loss

Blurred Vision

Carpal Tunnel Syndrome

Fainting

Bloating

Crossed Eyes

Joint Pain

Fever

Bowel Changes

Hair Loss

Constipation

Double Vision

Neck Pain

Hair Growth Excessive

Diarrhea

Earaches

Shoulder Pain

Night Sweats

Gas

Ear Discharge

Sleeping Problems

Hemorrhoids

Hay Fever

Thirst - Excessive

Indigestion

Hoarseness

Weight Gain

Intestinal Disorder

Hearing Loss

Weight Loss

Lactose Intolerance

Nose-Bleeds

Nausea

Persistent Cough

Rectal Bleeding

Persistent Runny Nose

Anxiety

Stomach Pain

Recurring Sore Throat

Depression

Vomiting

Ringing in Ears

Loss of Interest

Vomiting Blood

Sinus Problems

Mental Health

Joint Swelling

Men Only
Lump in Testicles
Penile Discharge
Sore on Penis

Women Only
Abnormal Pap Smear
Bleeding between Periods

Vision Halos

Feeling Hopeless

Breast Lump

Genitourinary

Hearing Voices

Extreme Menstrual Pain

Respiratory

Marital Problems

Blood in Urine

Panic Attacks

Lack of Bladder Control

Coughing

Trouble Concentrating

Frequent Urination

Coughing Up Blood

Suicide Thoughts / Attempts

Painful Urination

Shortness of Breath

Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge

Wheezing

Skin

Neurological

Acne

Coordination Problems

Bruise Easily

Convulsions

Cardiovascular
Chest Pains

Changes in Moles

Irregular Heart Beat

Dry / Sensitive Skin

Learning Disabilities

Circulation Problems

Eczema

Light-headedness

Heart Palpitations

Hives

Memory Loss

Rapid Heartbeat

Itching

Numbness / Tingling

Swelling of Ankles

Rash

Paralysis

Varicose Veins

Scars

Seizures

Sores That Wont Heal

Speech Problems
Tremors

Other Symptoms

Immunizations

Health Exams & Procedures

Please check and date the last time you had each exam or procedure performed.
Month & Year

Please check and date all immunizations you have had.

Month & Year

Month & Year

Month & Year

Cholesterol Test

MRI

Hepatitis A

MMR (Measles,

Colonoscopy

Physical Exam

Hepatitis B

Pneumonia

CT/CAT Scan

Cardiac Stress Test

HPV Vaccine

Polio

EKG

Ultra Sound

Echocardiogram

Check-In by

(Series of 3)

(Flu Shot)

Meningitis

Mumps, Rubella)

Tetanus

Assignment and Release:

I, the undersigned certify that I ( or my dependent) have insurance coverage with _______________ Are assigned
directly to NEW GEN MEDICAL PC all insurance benefits, if any, otherwise payable to me for services rendered. I
understand at I am financially responsible for all charges not paid by insurance. I hereby authorize the doctor to
release all information necessary secure the payment benefits. I authorize the use of this signature on all my
insurance submissions.
Signature ________________________________ Date ________________________________________

Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. The Notice contains a Patient Rights section describing your rights under the law. You have
the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our
Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for
treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall
honor that agreement. By signing this form, you consent to our use and disclosure of protected health information
about you for treatment payment and health care operations. You have the right to revoke this Consent, in writing,
signed by you. However such a revocation shall not affect may disclosures we have already made in reliance on you
prior consent. The Practice provides this from to comply with the Health insurance Portability and Accountability
Act of 1996 (HIPAA).

The patient understands that:

Protected health information may be disclosed or used for treatment, payment, or health care operations.

The Practice reserves the right to change the Notice of Privacy Practices.

The patient has the right to restrict the uses of their information but the Practice does not have to agree to
those restrictions.

The patient may revoke this Consent in writing at any time and all future disclosures will then cease.

The Practice may condition receipt of treatment upon the execution of this Consent.

This Consent was signed by:

Printed Name____________________________________________________
Signature ___________________________ Date _______________________