Examples Of Hospital Patient Intake Admission Details

Hospitals are a necessary part of healthcare, and patients rely on them for a variety of treatments and services. The hospital intake sheet form is an important document that helps to keep track of patients when they arrive at the hospital. This form includes information such as the patient's name, medical history, and insurance details. It's important for hospitals to have accurate information about patients so that they can provide the best possible care. The hospital intake sheet form is also used to bill patients' insurers for services rendered.

The listing has got information about the hospital intake sheet. You can learn its length, the typical time to complete the form, the blanks you'll need to fill in, and so forth.

QuestionAnswer
Form NameHospital Intake Sheet
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesexamples of hospital patient intake admission, hospital intake forms, admission intake form, get intake sheet pdf

Form Preview Example

Division of Plastic & Reconstructive Surgery

__ William G. Austen, Jr. MD

Wang Ambulatory Care Center

__ Curtis L. Cetrulo, Jr. MD

15 Parkman Street, Suite 435

__ Amy Colwell, MD

Boston, MA 02114

__ Jason S. Cooper, MD

__ Eric C. Liao, MD, Ph.D. __ Jonathan Winograd, MD __ Michael Yaremchuk, MD

Today’s Date:___________________________ MGH Unit #__________________________

Patient Name:_________________________________________________________________

Address: _____________________________________________________________________

City:____________________________________State:__________________Zip:__________

Home Phone:___________________________ Work/Cell Phone:______________________

Employer:______________________________ Occupation:___________________________

Date of Birth:_______________Age:________ Emergency Contact:____________________

Social Security Number:__________________ Relationship to Patient:_________________

Marital Status: M/ S/ D/ W No. of Children__ Contact Telephone:_____________________

E-mail Address:__________________________How did you hear about us?

 MGH website

 Physician Referral  Friend or Relative  Internet Search

 Magazine/Newspaper  Other

Primary Care Physician:________________________________________________________

Address:_______________________________________________Phone:_________________

Referred by (Physician):_________________________________________________________

Address:_______________________________________________Phone:_________________

INSURANCE INFORMATION:

Primary Insurance:_______________________ Policy Holder Name:_______________________

Policy Number:___________________________ Group Number:___________________________

Secondary Insurance:______________________ Policy Holder Name:_______________________

Policy Number:___________________________ Group Number:___________________________

Assignment and Release

I hereby authorize my insurance benefits to be paid directly to the Massachusetts General Physicians Office (MGPO) for services rendered. I hereby acknowledge that I am responsible for unpaid balances. I also authorize the above physician practice to release medical information necessary to process any claims submitted on my behalf.

Please note this important information about your insurance

We, the Massachusetts General Physicians Organization, participate with Medicare, Medicaid, Blue Cross/ Blue Shield and numerous Health Care Management organizations. If you are covered by a managed care plan, it is the responsibility of the patient to obtain prior authorization for all services rendered at this healthcare facility. A referral form, authorization number and /or name and number of your primary care physician (PCP) should be provided at the time of your visit. If you do not have the proper authorization or referral at the time of your visit, you agree to assume responsibility for all charges related to your visit. You are also required to pay all co-payments at the time of your visit.

Signed: ________________________________________

Date: ______________________

 

Patient Signature

Month/ Day

 

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Reason for Today’s visit:

______________________________________________________________________________

______________________________________________________________________________

Have you consulted other doctors regarding this problem? Y/N

If yes, please list:____________________________________________________________________

Have you had any previous surgery for this problem?________________________________________

PAST MEDICAL HISTORY:

GENERAL HEALTH: Excellent___ Good___ Fair ___ Poor___ Height_______ Weight___________

Date of last Physical Examination:______________________________________________________

Was an electrocardiogram performed? Y/N

Chest X-Ray Y/N

Are you pregnant? Y/N

Do you currently wear a Pacemaker or ICD ? Y/N

 

If yes, who is your Cardiologist: ________________________________ Telephone: ______________

OTHER CURRENT MEDICAL PROBLEMS (Please list)

__________________________________________________________________________________

__________________________________________________________________________________

What is your daily or previous consumption of: Coffee/Tea_____ Tobacco______Alcohol_______

Aspirin (Tylenol, Bufferin, Anacin, Contac, etc)____________ Steroids (Cortisone)_____________

CURRENT MEDICATIONS (Please list)

Include dosages (including birth control pills, diuretics, blood pressure or heart medication, tranquilizers, hormones, blood thinners, sleeping pills or pain medications, over the counter medications, vitamins and herbal supplements)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Do you have any Allergies to any medications? (Please list)

_________________________________________________________________________________

Do you have any other Allergies? (Please list)

_________________________________________________________________________________

Are you now or have you ever received psychiatric assistance? Y/N Name and address of Psychiatrist or Psychologist:

____________________________________________________________________________________

____________________________________________________________________________________

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PREVIOUS SURGERY (Please list with dates)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Have you had complications from previous surgery? Y/N If yes, please describe the complication:

____________________________________________________________________________________

________________________________________________________________________________

Has anyone in your family had complications from anesthesia?

Y/N

Do you bruise easily?

 

Y/N

PREVIOUS ILLNESSES (Place an X after any illness you have had)

Heart Murmur___

Rheumatic Fever___

Heart Attack____

Heart Disease___

High Blood Pressure___

Blood Transfusion___

Pneumonia___

Pleurisy___

Emphysema____

Kidney Trouble___

Bladder Trouble___

Thyroid Trouble_____

Hiatal Hernia___

Abnormal EKG___

Asthma____

Anemia___

Bleeding Disorder____

Jaundice____

Hepatitis___

Ulcer____

Arthritis____

Diabetes___

Phlebitis____

Epilepsy____

Abnormal Chest X-Ray___

AIDS____

Venereal Disease____

Tumor___

Cancer____

Stroke____

Nervous Disorder___

Glaucoma____

Albuminuria____

Nerve Deficit___

Kidney Stones____

Tuberculosis___

Other___________________________________________________________________________

PRESENT SYMPTOMS (Place an X after any symptoms you have now)

Fever/ Chills___

Excess Sweating___

Fatigue____

Vision Problem____

Eye Pain/Redness____

Hearing Trouble____

Nose Bleeds____

Throat Discomfort____

Cough____

Sputum_____

Bloody Sputum___

Wheezing____

Chest Pains___

Heat Intolerance____

Heart Skipping____

Shortness of Breath___

Swollen Feet or Ankles____

High Blood Pressure___

Jaundice____

Heartburn____

Difficulty Swallowing___

Abdominal Pain____

Nausea/Vomiting____

Vomiting Blood____

Black Stools____

Rectal Bleeding____

Diarrhea____

Acid Indigestion____

Backache____

Arthritis____

Night Time Urine____

Bruise Easily____

Bleed Easily____

Increased Thirst____

Increased Urine____

Fainting_____

Numbness_____

Tremor____

Muscle_____

Weakness____

Nervousness_____

Depression____

Other_________________________________________________________________________

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