Our Response to Coronavirus (COVID-19)

We remain committed to providing our patients the best possible healthcare in this community. We will remain open during this difficult time and provide all necessary cleaning and sanitation to assure patient and staff safety. We can provide telemedicine appointment if you feel uncomfortable with visiting us in the office but need to arrange those through the office phone system. We will be working our regular hours as well as have our Saturday morning walk in clinic.

Patient Demographics

Full Name
Nickname/Preferred Name
Date of Birth
Social Security Number
Mailing Address
Email Address
City
State
Zip
Home Telephone Number
Mobile Telephone Number
Marital Status
Race
Ethnic Group
Preferred Language
Preferred Religion
Preferred Gender:
Male    
Female

Primary Insurance

Name
ID#
Group#

Secondary Insurance

Name
ID#
Group#

Responsible Party Only if not patient

Full Name
Date of Birth
Social Security Number
Mailing Address
City
State
Zip
Home Telephone Number
Mobile Telephone Number
Relationship to Patient

Emergency Contact/Notification of Kin - Someone not in household

Full Name
Relationship to Patient
Telephone Number
Full Name
Relationship to Patient
Telephone Number
Dear Valued Patient,

We are pleased that you have chosen to partner with us in the care of your health; however, in order to insure that you receive the best care possible and are taken care of in the most efficient way, we ask that you review the following office policies.

Compliance:

  • We ask that you make every effort to comply with the provider's recommendations regarding routine follow-up office visits, mediations, labwork/tests ordered, procedures, referralsetc.

Medication:

  • Please bring ALL of your current medications (or a list) to EVERY appointment.

Pain Management:

  • Our office is not a pain management clinic. A referral will be made to a pain management specialist for chronic pain medication management at the discretion of Dr. Hill and/or provider.

Results

  • A follow up appointment is required minimally every quarter of the year and labwork or imaging results will be reviewed at the time of your appointment. You will receive a copy of the results at your scheduled follow-up appointment.

Cancellation

  • Time has been specifically reserved for your appointment, procedure, or treatment. Please call at least 24 hours in advance to cancel an appointment. There is a $25 charge if you fail to show for a scheduled appointment or cancel with less than 24 hours notice.

Release of Information / Assignment of Benefits

I authorize the release of any medical information necessary to process my insurance claim. I authorize and request payment of medical benefits directly to my physicians. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me; I understand and agree that regardless of my insurance status I am responsible for any balance of my account.

I Agree

RELEASE OF PRESCRIPTION HISTORY

By signing this consent form you are agreeing that your provider at West Volusia Family & Sports Medicine may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it. This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to West Volusia Family & Sports Medicine to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

I Agree

Family, Significant others, and friends.

Under certain circumstances, we may disclose PHI (Protected Health Information) to family members, other relatives, or close personal friends or others that you identify to improve communication of relevant information (most commonly laboratory results, prescription issues and or changes, appointment scheduling. etc.) to their involvement in your care or payment related to your care; or to notify them of your location, general condition, or death.

In compliance with this office's HIPPA policy, I am authorizing West Volusia Family & Sports Medicine's staff to release PHI as necessary to support and assist in my care. Please list each individual authorized to receive information as stated above and provide us with the information requested.

Please indicate if you wish to have your personal health care information released to your spouse, children, or significant other below:

Person 1:
Name:
Relationship:
Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 2:
Name:
Relationship:
Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 3:
Name:
Relationship:
Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.
Person 4:
Name:
Relationship:
Address:
City:
State:
Zip:
Telephone:
Date:

I authorize the release of my PHI to this person.

I hereby expressly acknowledge the receipt of West Volusia Family and Sports Medicine's Notice of Privacy Practices.

Health History Questionnaire

All questions contained in this questionnaire are protected by privacy acts under HIPPA and will become part of your medical record. Fill in the blanks or check appropriate answers.

Today's Date

Previous Primary Care Providers

Previous Provider 1
Provider:
Practice Name:
Telephone Number:
Fax Number:
Previous Provider 2
Provider:
Practice Name:
Telephone Number:
Fax Number:

Current Specialists (Ex:Cardiologist, Pulmonologist, Endocrinologist, Nephrologist, etc)

Current Provider 1
Provider:
Practice Name:
Telephone Number:
Fax Number:
Current Provider 2
Provider:
Practice Name:
Telephone Number:
Fax Number:
Current Provider 3
Provider:
Practice Name:
Telephone Number:
Fax Number:
Current Provider 4
Provider:
Practice Name:
Telephone Number:
Fax Number:

Patient Preferences

Preferred Pharmacy
Pharmacy Name:
Telephone Number:
Address:
Preferred Laboratory
Laboratory Name:
Telephone Number:
Address:
Preferred Imaging Center
Imaging Center Name:
Telephone Number:
Address:
Preferred Hospital
Hospital Name:
Telephone Number:
Address:

Reason To Establish At WVFSM/Any Concern That Needs to Be Addressed At First Office Visit

Allergies- List Medication Allergies, Food Allergies, Environmental Allergies- Include Reactions

Examples: Bactrim(Anitibiotic) - Generalized Rash; Bees - Anaphylaxis

Allergy Type and Reaction
Allergy Type and Reaction
Allergy Type and Reaction
Allergy Type and Reaction
Allergy Type and Reaction

Current Medications:

Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?

Past Medical History

Check if Experienced Any of the Following Childhood Illnesses:

Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio
Pertussis
RSV

Current or Previously Diagnosed Medical Conditions

Ophthamology

Glaucoma
Cataracts
Uveitis
Conjunctivitis

ENT

Ear Infection
Nasal Polyps
Hearing Loss
Tinnitus

Pulmonary

Asthma
COPD
Fibrosis
Sarcoidosis
Pulm Nodules

Cardiovascular

Hypertension
Cholesterol
Heart Attack
Murmur
At Fibrillation
Coronary Artery Disease

Gastroenterology

GERD
Diverticulosis
Colon Polyps
Chron's/UC
IBS
Hemorroids

Genitourinary

Incontinence
Bladder Prolapse
BPH
Erectile Dysfunction

OB/GYN

PCOS
Endometriosis
Irregular Menses
Vaginal Prolapse

Musculoskeletal

Osteoarthritis
Spondylosis
Herniated Disc
Fracture
Osteopenia/Osteoporosis

Neurology

Migraines
Tremor
Parkinson's
Dementia
Multiple Sclerosis

Hematology/Onc

Anemia
Blood Clot
Transfusion
Cancer (Specify Type)

Dermatology

Acne
Rash
Fungal Infection

Immune/Allergy

Allergy
Hives
Immune Deficiency

Endocrinology

Hypo or Hyper Thyroid
Diabetes
Addison/Cushing
Testosterone Deficiency

Nephrology

Chronic Kidney Disease
Polycystic Kidney
Renal Cell Carcinoma

Rheumatology

Rheumatoid
Lupus
Sjogren's
Fibromyalgia

Infectious Disease

Hepatitis C
Gonorrhea
Chlamydia
HIV
Lyme Disease

Psychiatry

Depression
Anxiety
Bipolar
Schizophrenia
ADD/ADHD

Podiatry

Heel Spur
Bunion
Hammer Toe
Plantar Fasciits

Surgical Procedure History: Provide Date and Surgeon/Provider If Known

Ophthamology

Cataracts: Left    Right
Yes No N/A

ENT

Tonsillectomy
Yes No N/A
Adenoidectomy
Yes No N/A
ET Tubes
Yes No N/A

Pulmonary/Chest

Bronchoscopy/EBUS
Yes No N/A
VATS (Video-Assisted Thorocotomy)
Yes No N/A

Cardiovascular

Carotid Endarterectomy
Yes No N/A
Cardiac Catheterization
Yes No N/A
Stent Placement
Yes No N/A
Pacemaker/AICD
Yes No N/A
Aortic Aneurysm Repair
Yes No N/A
Vascular Bypass
Yes No N/A

Gastroenterology

EGD
Yes No N/A
Colonoscopy
Yes No N/A
Cholecystectomy
Yes No N/A
Gastric Bypass
Yes No N/A
Appendectomy
Yes No N/A

Genitourinary

Bladder Suspension
Yes No N/A
TURP
Yes No N/A

OB/GYN

Hysterectomy
Yes No N/A
Ovaries/Tubes
Yes No N/A
Tubal Ligation
Yes No N/A

Breast

Mastectomy: Left    Right
Yes No N/A
Lumpectomy
Yes No N/A
Biopsy
Yes No N/A

Musculoskeletal

Hip Replacement: Left    Right
Yes No N/A
Knee Replacement: Left    Right
Yes No N/A
Herniated Disc Repiar
Yes No N/A

Dermatology

Moh's Surgery
Yes No N/A

Endocrinology

Thyroidectomy: Partial    Total
Yes No N/A

Nephrology

Nephrectomy: Left    Right
Yes No N/A

Podiatry

Bunion
Yes No N/A
Hammer Toe
Yes No N/A

Other

OTHER:
Yes N/A
OTHER:
Yes N/A
OTHER:
Yes N/A
OTHER:
Yes N/A

Hospitalizations Within The Last 3 Years

Dates Hospitalized
Reason For Hospitalization
Name of Hospital
Dates Hospitalized
Reason For Hospitalization
Name of Hospital
Dates Hospitalized
Reason For Hospitalization
Name of Hospital
Dates Hospitalized
Reason For Hospitalization
Name of Hospital
Dates Hospitalized
Reason For Hospitalization
Name of Hospital

Family Health History

(Please complete to the best of your ability)

Father
Age
Alive   
Deceased
Medical Conditions
Mother
Age
Alive   
Deceased
Medical Conditions
Sibling
M   
F
Age
Alive   
Deceased
Medical Conditions
Sibling
M   
F
Age
Alive   
Deceased
Medical Conditions
Sibling
M   
F
Age
Alive   
Deceased
Medical Conditions
Sibling
M   
F
Age
Alive   
Deceased
Medical Conditions
Children
M   
F
Age
Alive   
Deceased
Medical Conditions
Children
M   
F

Age
Alive   
Deceased
Medical Conditions
Children
M   
F
Age
Alive   
Deceased
Medical Conditions
Children
M   
F
Age
Alive   
Deceased
Medical Conditions
Grandmother (Maternal)
Age
Alive   
Deceased
Medical Conditions
Grandfather (Maternal)
Age
Alive   
Deceased
Medical Conditions
Grandmother (Paternal)
Age
Alive   
Deceased
Medical Conditions
Grandfather (Paternal)
Age
Alive   
Deceased
Medical Conditions

Social History: Health Habits and Personal Safety

All Questions in This Section Are Optional and Will Be Confidential in Compliance with Privacy Policies

Meals Consumed

Number of Meals Consumed on Daily Basis:

Smoking History-Cigarettes/Cigars, Chew Tobacco

Are you a Smoker? Yes No
Do you chew tobacco? Yes No
I smoke cigarettes: packs per day for: years.
I quit in: , I smoked: packs per day for years.
Are you interested in quitting? Yes No

Alcohol Consumption

None Beer Wine Mixed Drinks/Coolers Other
Number of servings per week?
Concerned about your drinking? Yes No
History of Blackouts? Yes No
Binge Drinking? Yes No
Drive After Drinking? Yes No

How many caffeinated drinks do you consume?

None Coffee Cola Tea Other
Number of cups/cans per day?

Exercise Habits on a Weekly Basis

Sedentary (no exercise)
Mild Exercise (walk 3 blocks, climb stairs, golf)
Occasional Exercise (work or recreation, less than 4x / week for 30 min)
Regular Exercise (work or recreation, 4x / week or more for 30 min)

Health and Personal Safety

Do you live alone? Yes No
Do you have frequent falls? Yes No
Do you rely on contacts or glasses to correct vision? Yes No
Do you rely on hearing aids to correct loss of hearing? Yes No
Do you rely on dentures? Yes No

Personal Wishes

Do you have an Advance Directives or Living Will? If Yes, please furnish a copy for your record. Yes No
Have you designated a Healthcare Surrogate? If yes, please furnish a copy of your designation for your records. Yes No
Are you an Organ Donor? Yes No

Travel History

Any Travel Outside of the US in the Past 6 Months? Yes No

Urinary/Infectious Concerns

Do you have a history of recurrent urinary tract, bladder, or kidney infections? Yes No
Do you have problems with control of urination? Yes No
Do you feel any pain or burning with urination? Yes No
Number of times you get up during the night to urinate?
Have you had any of the following infections? HPV Herpes HIV Chlamydia Gonorrhea

Sexual/Reproductive Health

Are you sexually active? Yes No
If not trying for pregnancy, what methods are used for prevention?
Any discomfort (pain or dryness) with intercourse? Yes No
Any problems with frequency or loss of interest in intercourse? Yes No

Women

Age at Start of Menstruation?
Age at Menopause:
Date of Last Menstral Period:
How many pregnancies?
How many live births?
Are you pregnant?
Yes   
No
Are you breastfeeding?
Yes   
No

Men

Any difficulty with erection or ejaculation?
Yes   
No
Any testicle pain or swelling?
Yes   
No

Vaccination History

Tetanus
Influenza
Hepatitis (series of 3)
Pneumococcal 23
Prevnar 13
MMR (Measles, Mumps, Rubella)
Varicella
Shingles
HPV
Meningiococcal

Preventative Screenings

Last Physical/Wellness Exam
Eye Exam
Dental Exam
Hearing Exam
Diabetes Screening (Labwork)
Cholestrol Screening (Labwork)
Screening Mammogram
PAP Smear
Rectal Exam
Prostate Soecific Antigen (PSA)
Lung Cancer Screening (CT)
Colonoscopy/Colguard
Osteoporosis (DEXA)
Abd Aortic Aneurysm (AAA)

UNIVERSAL PATIENT AUTHORIZATION FORM FOR FULL DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT & QUALITY OF CARE

***PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW***

Patient (name and information of person whose health information is being disclosed)

Name (First Middle Last)
Date of Birth (mm/dd/yyyy)
Mailing Address
City
State
Zip

You may use this form to allow your healthcare provider to see and obtain access to your health information. Your choice on whether to sign this form will not affect your ability to get medical care or health insurance converage and cannot be used as the basis for denial of health services.

By signing this form, I voluntarily authorize and give my permission and allow disclosure:

OF WHAT: ALL MY HEALTH INFORMATION including any information about sensitive conditions (if any) [click for details]

FROM WHOM: ALL information sources [click for details]

TO WHOM: Specific person(s) or organization(s) permitted to receive my information (must be a healthcare provider):

Person/Organization Name: John Hill M.D. - West Volusia Family and Sports Medicine

Phone: (386) 774-0016

Address: 1590 S. Sr 15A - Suite #100, Deland, FL 32720

Fax: (386) 774-0606

PURPOSE: To provide me with medical treatment and related services, and to evaluate and improve patient safety and the quality of medical care provided to all patients.

EFFECTIVE PERIOD: This authorization/permission form will remain in effect until the earlier of: my death or the day I withdraw my permission.

WITHDRAWING OF MY PERMISSION: I can withdraw my perrmission at any time by giving a written notice to the person or organization named above in "To Whom."

In addition:

  • I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
  • I understand that there are some circumstances in which this information may be redisclosed to other persons [click for details]
  • I understand that refusing to sign this form does not stop disclosure of my health information that is ptherwise permitted by law without my specific authorization or permission.
  • I have read all pages of this form and agree to the disclosures above from the types of sources listed.
Signature of Patient or Patient's Legal Representative
Date Signed (mm/dd/yyyy)
Name of Legal Representative (if applicable)

Check one to describe the relationship of Legal Representative to Patient (if applicable):

Parent
Guardian
Other:

Authorized Pickup for Controlled Substance Prescription ONLY

I, , hereby give permission to the following people to have access to be able to pick up my controlled substance prescriptions with West Volusia Family and Sports Medicine.
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient

The above names can speak to any of the West Volusia Family and Sports Medicine staff in regards to picking up my controlled substance prescriptions.
I Accept


Granting Access to my Medical Records and History

I, , hereby give permission to the following people to have access to my medical history and records with West Volusia Family and Sports Medicine.
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient

The above names can speak to any of the West Volusia Family and Sports Medicine staff about my health and well-being.
I Accept



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