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Name:_____________________________________________ Responsible Party:___________________________________ Address:___________________________________________ Relationship to You:__________________________________ City:________________________ State:_____ Zip:_________ I do NOT authorize University Physicians to file my insurance: Patient’s Date of Birth: ____/____/____ Age: __________ Patient Signature: ___________________________________ Social Security #: ___________________________________ Primary Insurance:___________________________________ ID #:_______________________Group #:_________________ Marital Status: Single Married Widowed Divorced Insurance Phone#: (______) ___________________ Insured Name: ______________________________________ Secondary Insurance:_________________________________ ID #:_______________________Group #:_________________ Insurance Phone#: (______) ___________________ Insured Name: ______________________________________ Primary Physician: ___________________________________ Authorization #: _____________________________________ Referring Physician: __________________________________ Referring Physician Phone #: (______) ___________________ Language: __________________________________________ Address:____________________________________________ Home Phone#: (______) _____________________ City:________________________ State:______ Zip:_________ Mobile Phone#: (______) _____________________ I hereby authorize exchange of information with my physician: Employer: __________________________________________ Patient Signature: ___________________________________ Employer’s Phone#: (______) _____________________ Preferred Pharmacy:__________________________________ Domestic Partner’s Name: ____________________________ Preferred Pharmacy Phone #: (______) ___________________ Partner’s Date of Birth: ____/____/____ Age: __________ Social Security #: ___________________________________ Emergency Contact Name: _____________________________ Employer: __________________________________________ Address:____________________________________________ Employer’s Phone#: (______) _____________________ State:_________________ Zip:____________ Age:_________ Reason for Visit: ____________________________________ Home Phone#: (______) ___________________ ___________________________________________________ Work Phone#: (______) ______________________________________________________________________ Relationship to You: __________________________________ University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net How did you hear about University Physicians?: ___________________________________________________________Are you a SEAHEC Employee? Yes No If yes, SEAHEC employee, number: ____________________________If we need to call you at home, work, or on your cell, may we leave a message: Yes No University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net Treatment History Please circle the appropriate response and answer to all questions completely.
Have you been diagnosed with (check all that apply) Have you ever fallen asleep while driving? Do you feel rested when you wake up in the morning? Do you ever wake from a deep sleep choking, coughing or gasping for Has anyone ever told you that you stop breathing while you are sleeping? Have you ever had a sleep study? If yes, did you have sleep apnea? If you have sleep apnea, do you use c-pap or bi-pap? Settings: Have you ever had an ulcer or non-healing sore on your leg? Have you ever seen a heart specialist for cardiac problems or had a heart If yes, please list physician’s name, date of work up, test(s) done and findings (please include copies of test/notes from the cardiologist): ____________________________________________________________________Have you ever had a blood clot in your legs or lung? Do you currently take aspirin products, motrin, ibuprofen, or blood-thinners? Are you currently seeing a psychologist, psychiatrist or therapist for treatment? If yes, who is treating you? _____________________________________________________________________Have you been hospitalized for depression, anxiety, or other related problems? If yes, please give date(s) and reason(s):Have you ever had surgery for weight loss? If yes, please list surgeon’s name, type of obesity surgery and the year of the surgery: ____________________ ____________________________________________________________________________________________ List all of the medication you currently take: Use back of form for any additional medications, if any. University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net What type of exercise are you currently doing? ___________________________________________________________________________________________________________________________________Number of Times a Week: ____________ Gym Memberships: _________________________________What type of exercises do you hope to do after surgery? ________________________________________________________________________________________________________________________ Please list all diet/exercise programs you have tried in the past 5 years, if any.
Worked with dietitianPhysician supervisedPhen-Fen (Redux)XenicalMeridiaRichard SimmonsWeight Loss ForeverNutriSystemJenny CraigOvereaters AnonymousHerbal Life/MetabolifeDiet CenterSENSAWeight Watchers L.A. Weight LossOptifast/MedifastAtkins DietSlimfastMiami DietPaleo DietThe ZoneThe Biggest Loser DietSouth Beach DietHypnosisBHCGPhenterminePortion Control DietTreadmillFree WeightsOther: _____________________________________ Use back of form for any additional weight loss plans or exercise types, if any. University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net Highest Weight1 Year Ago2 Years Ago3 Years Ago4 Years Ago5 Years Ago Please CHECK all eating habits that may apply. Complaints Below is a list of problems and complaints people sometimes have. After you read the list, use the scale below to describe how much the problem has bothered you during the past ____Other people being aware of private thoughts ____Unwanted thoughts, words, or ideas that won’t ____Fear of traveling on buses, trains, or airplanes ____Having to avoid certain things, places or activities ____Idea that someone else can control your ____Feeling others are to blame for your troubles ____Having thoughts that are not your own ____Feeling afraid in open spaces or on the street ____Having urges to beat, injure, or harm someone ____Having urges to break or smash things ____Hearing voices that other people do not hear ____Having ideas or beliefs that others do not share ____Feeling that most people cannot be trusted ____Feeling nervous when you are left alone ____Feeling so restless you couldn’t sit still ____Temper outbursts that you could not control ____Feeling afraid to go out of your house ____Feeling that familiar things are strange or unusual ____The idea you should be punished for your sins ____The idea something is wrong with your mind University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net PATIENT OR REPRESENTATIVE AGREEMENT TO PAY UNIVERSITY PHYSICIANS 1. I have read and understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the cost of the interest, collection and legal action (if required).
2. I authorize my insurance carrier to release information regarding my coverage to University Physicians. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state, accreditation agency, or any physician/insurance carrier(s) needed. I also agree to a review of my records for purposes of internal audits, research and quality assurance reviews within University Physicians. 3. My right to payment for pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nurs- ing/physician services including major medical benefits are hereby assigned to University Physicians. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insur-ance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services rendered from my dependent or me. In the event my insurance does not accept Assignment of Benefits, or if payments are made directly to my representative or me, I will ensure such payment to University Physicians. Please explain Representative’s relation to the Patient (including a description of the Representative’s authority to act on behalf of the Patient: ________________________________________________________________________________________________________________________________________________________________________________________ University Physicians, A Service of SEAHEC 2221 S. 17th St. Wilmington NC 28401 910 815.5081 fax 910 815.5099 www.seahec.net

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