BSA - CT Surgery New Patient Questionnaire

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* 1. Patient's Information

Last Name

First Name

Middle Initial

Social Security Number

Date of Birth

Age

Gender (Male / Female)

Marital Status (Married / Divorced / Widowed / Single)

Mailing Address

City

State

Zip

Home Phone Number

Work Phone Number

Other Phone Number

Email Address

Employer

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* 2. Emergency Contact’s Information

Last Name

First Name

Middle Initial

Home Phone Number

Work Phone Number

Other Phone Number

Relationship to Patient

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* 3. Responsible Party’s Information (if different from patient)

Last Name

First Name

Middle Initial

Social Security Number

Date of Birth

Age

Gender (Male / Female)

Marital Status (Married / Divorced / Widowed / Single)

Mailing Address

City

State

Zip

Home Phone Number

Work Phone Number

Other Phone Number

Email Address

Employer

Referral Information

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* 4. Did another physician refer you to BSA Cardiothoracic Surgery?

Yes

Physician Name

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* 5. What is the name of your primary or family physician?

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* 6. Please write the name(s) of any physicians we should send your medical records to from your visit at BSA Cardiothoracic Surgery.

Workman’s Compensation

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* 7. Is your illness related to an on the job injury?

Yes

If yes, please complete an insurance information form.

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* 8. I authorize the release of any medical information necessary to process a claim on my behalf and request payment of any insurance benefits to BSA Amarillo Surgical group or myself. I consent for BSA Medical Group to obtain my medication prescription history and place my prescription orders through the electronic prescribing system.

Signature

Date

Medical History Information

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* 9. Why are you being seen at BSA Cardiothoracic Surgery?

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* 10. List any medications that you are currently taking. If you are being seen in the hospital, list medications prior to admission. Please include your over-the-counter medications, prescription medications, vitamins, minerals or herbal supplements.

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* 11. Are you allergic to any medications?

Yes

Please list the medication(s) and your reaction(s)

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* 12. List any other medical conditions and/or previous illnesses or disorders.

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* 13. List previous major injuries.

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* 14. List previous operations/surgeries.

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* 15. List any diagnostic testing you have received related to your current condition.

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* 16. (Females Only) At what age did you begin menstruating?

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* 17. (Females Only) Have you stopped menstruating?

Yes

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* 18. (Females Only) Do you have regular periods?

Yes

N/A

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* 19. Do you take female hormones?

Yes

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* 20. (Females Only) Do you have any family members with breast cancer?

Yes

If yes, please list if it was from your mother or father’s side and at what age they were diagnosed.

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* 21. (Females Only) Do you have any family members with ovarian cancer?

Yes

If yes, please list if it was from your mother or father’s side and at what age they were diagnosed.

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* 22. Is your mother living?

Yes

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* 23. Is your father living?

Yes

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* 24. How old is your mother, or how old was she when she passed?

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* 25. How old is your father, or how old was he when he passed?

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* 26. Please check all that apply for your father’s medical history:

Stroke

Diabetes

High Blood Pressure

Heart Disease

Tuberculosis

Alcoholism

Jaundice

Bleeder

Obesity

Gout

Asthma

Cancer

Mental Illness

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* 27. Please check all that apply for your father’s medical history:

Stroke

Diabetes

High Blood Pressure

Heart Disease

Tuberculosis

Alcoholism

Jaundice

Bleeder

Obesity

Gout

Asthma

Cancer

Mental Illness

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* 28. List out any sibling or children you have with their ages.

Do any of your siblings or children have the following?