PATIENT INFORMATION RECORD

Part One: Patient (Please fill the form)

First Name

Last Name

Address

Phone No

Cell Phone No

Email Address

Date of Birth

Age

Sex (Male / Female)

Social Security No

Marital Status (Single/ Married /Widow /Divorced /Separated)

Name of Spouse

Phone No

Emergency Contact (other than above) :

Name

Relation

Phone No

Name of Employer

Phone No

Primary Care Physician

Phone No

Patient Referred By

Part Two: Insurance

Please bring your DRIVERS LICENSE (or STATE ID), and all INSURANCE CARDS for the receptionist

Primary Insurance:

If subscriber other than patient:

Subscriber Name

subRelation

DOB

Secondary Insurance:

If subscriber other than patient:

Subscriber Name

Relation

DOB

Patient Signature

Date

	Fingers		Hands	Wrist
	Elbow		shoulder	Knee
	feet		Hip	Back	Neck
First Diagnosed as:		Where:
What Tasts Were Abnormal
	ANA		Sed Rate/CRP
	Rheumatoid Factor		Uric Acid	Biospy

Have you ever side effect from these drugs?	No	Yes	Which Medicine/ What Side Effect :
Work / Life Style / Family / Habits / Exercise
Martial Status:	Single	Married	Divorced	Widowed

Who Lives With you ?	How many Kids?
Do You Have Help at Home? :	No	Yes	Who :

List All prescription medications you are now taking(include over the counter meds and natural/herbal pills)
OVER The Last Week, were you able to:	Without ANY Difficulty	With SOME Difficulty	With MUCH Difficulty	UNABLE To Do
Dress yourself, including tying shoelaces and doing buttons?	1	2	3	4
Get in and out of bed?	1	2	3	4
Lift a full cup or glass to your mouth?	1	2	3	4
Walk outdoors on flat ground?	1	2	3	4
Wash and dry your entire body?	1	2	3	4
Bend down to pick up clothing from the floor?	1	2	3	4
Turn regular faucets on and off?	1	2	3	4
Get in and out of a car, bus, train, or airplane?	1	2	3	4
Walk two miles or three kilometers, if you wish?	1	2	3	4
Participate in recreational activities and sports as you would like if you wish?	1	2	3	4
Deal with feelings of anxiety or being nervous?	1.1	2.2	3.3	4.4
Get a good night's sleep?	1.1	2.2	3.3	4.4
Deal with feelings of depression or feeling blue?	1.1	2.2	3.3	4.4

	Mild	Moderate	Severe
a. LEFT FINGERS	1	2	3
b. LEFT WRIST	1	2	3
c. LEFT ELBOW	1	2	3
é. LEFT HIP	1	2	3
f. LEFT KNEE	1	2	3
g. LEFT ANKLE	1	2	3
h. LEFT TOES	1	2	3
i. RIGHT FINGERS	1	2	3
j. RIGHT WRIST	1	2	3
k.RIGHT ELBOW	1	2	3
L. RIGHT SHOULDER	1	2	3
m. RIGHT HIP	1	2	3
n. RIGHT KNEE	1	2	3
Oo. RIGHT ANKLE	1	2	3
p. RIGHT TOES	1	2	3
q. Neck	1	2	3
q. Back	1	2	3

ATTENTION ALL PATIENTS

Every day new insurance companies are forming and present companies are changing. Consequently, it is impossible for us to know exactly what your insurance company will cover.

Please check with your insurance carrier so you will be aware of your coverage regarding office visits, x-rays, lab tests, emergency visits, procedures, etc. It is to your benefit to be well informed to prevent having to pay for a service that may have been covered if you had a referral, prior authorization, second opinion, etc.

1). If you fail to obtain a referral or prior authorization needed, you will be responsible for the service rendered
2). If you do not inform us of any insurance changes, you will be responsible for the service rendered.
3). If your insurance plan does not cover services that are rendered, you will be responsible for those services.
4). You are responsible for all co-pays and deductibles.
5). If you have no insurance, you are totally responsible for all services rendered
6). You may talk to us about payment plan arrangements.

Patient Signature

Date

Our practice may use and disclose your protected health information in order to obtain reimbursement for your healthcare services. This includes, among others; billing, claims management, collection activities, verification of insurance coverage/benefits, and pre-certification of services. Additional information of use and disclosure is described in our notice of privacy practices provided and posted.

I certify that the information I have reported with regard to my insurance coverage is correct and request the payment from my insurance company to be made directly to Shores Rheumatology (or the party who accepts assignment).

Patient Signature

Date

Shores Rheumatology, PC

Andrew J. Sulich, MD · Amar Q. Majjhoo, MD
Daric Mueller, PA-C · Rebecca Wideman, NP-C
Phone: 586-777-7577 · After-hours: 586-285-6263

Name:

Date Of Birth:

ADDRESS:

| hereby give my consent to: Dr(s):

to provide Shores Rheumatology with a summary of medical history - specifically: All pertinent information for Rheumatology evaluation, laboratory results, x-ray, imaging rac. and any other related diagnostic reports.

PROMPT ATTENTION WOULD BE APPRECIATED!
THANK YOU.

Patient Signature:

Authorized Signature if other than patient :

Date :

Uveitis	Seizures	Stroke or TIA
Neuropathy	Depression	Alcohol Abuse
Hypertension	Diabetes	Anemia
Heart Attack	COPD	Heart Failur
A-fib	High Cholesterol	Skin Problem
Psoriasis	Thyriod Problem	Cancer
Asthma	COPD	Tuberculosis
(+) TB Test	Lupus	Gallstones
Hepatitis	Kidney Stone	Chornic Kidney Disese
Pancreattis	Stomsch Ulcers	Crohns Disease
Ulcerative Colitis	Glaucoma	Cataract
Motor Accident	Frequent Falls	Miscarriage(s)
Blood Clots	TMJ/Jaw problems	Migraine
Sleep apnea	Osteoarthritis	Rheumatoid arthritis
AnkylosingSpondylitis	Osteoarthritis	Hip fracture
Myositis	Scleroderma	Fibromyalgia
Lupus	Gout	Vasculitis
Carpal Tunnel	Sjogren syndrome	Tendinitis
Juvenile Arthritis	Disc disease

Neck Surgery	Back Surgery	Joint replacement --> Which joints?
Arthroscopy	Fracture Repair	Tonsillectomy
Appendectomy	Gall Bladder removed	Hysterectomy
Hernia repair	Breast surgery	Colonoscopy
Heart bypass	Heart stent/PCI	Arterial stent
Thoracentesis	Intestine surgery	Thyroidectomy
Cataract surgery	Vitrectomy	Eye injection
Glaucoma surgery	Liver biopsy	TIPS
Organ transplant	Thrombectomy

List All prescription medications you are now taking(include over the counter meds and natural/herbal pills)
SrNo	Drug Name	Dose	How Many Times/day
1
2
3
4
5
6
7
8
9
10

Pepcid	Prevacid	Prilosec
Protonix	Nexium	Tagamet
Zantac	Advil	Aleve
Anacin	Anaprox	Ansaid
Arthrotec	Aspirin	Celebrex
Daypro	Ibuprofen	Indocin
Mobic	Motrin	Naproxen
Relafen	Tolectin	Vioxx
Uloric/Febuxostat	Probenacid	Krystexxa
Benlysta	Auranofin	Azathioprine
CellCept	Cyclosporine	Cytoxan
Prednisone	Acthar gel	Medrol Pack
Cosentyx	Taltz	Otezla
Stellara	Skyrizi	Tremfya
Methotrexate	Sulfasalazine	Plaquenil
Leflunomlde	Remicade	Humira
Enbrel	Cimzia	Simponi
Actemra	Kevzara	Rituxan
Xeljanz	Olumiant	Rinvoq
Kinaret	Ambien	Ativan
Halcion	Klonopin	Lunesta
Restoril	Valium	Xanax
Celexa	Desyrel	Elavil
Trazodone	Cymbalta	Lyrica
Neurontin	Wellbutrin	Effexor
Lexapro	Celexa	Pull
Prozac	Savella	Seroquel
Effexor	Ability	Anti-psychotics
Chantk	Zyban	Opioids
Tramadol	Ultracet	Vicodin
Baclofen	Flexeril	Flexeril
Skelaxin	Zanaflex	Cholesterol/ Statins
Flu vaccine	Hepatitis vaccine	Pneumovax
Guardasil-9	Shingles vaccine	Drug study
Joint Injections	CBD oil	Marijuana product
Kratom

No Pain:
Pains is Bad it Colud Be:	0	0.5	1.0	1.5	2.5	3	3.5	4	4.5	5	5.5	6	6.5	7	7.5	8	8.5	9	9.5	10